Provider Demographics
NPI:1417576067
Name:BITTLE, BLAKE AMELIA (RD)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:AMELIA
Last Name:BITTLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 72ND ST APT 17G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4542
Mailing Address - Country:US
Mailing Address - Phone:609-439-1238
Mailing Address - Fax:
Practice Address - Street 1:18 W 21ST ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6923
Practice Address - Country:US
Practice Address - Phone:212-645-6903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86151549133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered