Provider Demographics
NPI:1407121098
Name:PAUL, RENALD (CDN)
Entity Type:Individual
Prefix:MR
First Name:RENALD
Middle Name:
Last Name:PAUL
Suffix:
Gender:M
Credentials:CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 VAN PELT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-2410
Mailing Address - Country:US
Mailing Address - Phone:718-448-0363
Mailing Address - Fax:718-448-0363
Practice Address - Street 1:187 VAN PELT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-2410
Practice Address - Country:US
Practice Address - Phone:718-448-0363
Practice Address - Fax:718-448-0363
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04260133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist