Provider Demographics
NPI:1568123487
Name:HAGEN-REVELINS, CECILIA (RDN, CDN)
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:HAGEN-REVELINS
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:CECILIA
Other - Middle Name:
Other - Last Name:HAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, CDN
Mailing Address - Street 1:21 HILTON RD
Mailing Address - Street 2:
Mailing Address - City:DRYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13053-9709
Mailing Address - Country:US
Mailing Address - Phone:607-288-3441
Mailing Address - Fax:
Practice Address - Street 1:21 HILTON RD
Practice Address - Street 2:
Practice Address - City:DRYDEN
Practice Address - State:NY
Practice Address - Zip Code:13053-9709
Practice Address - Country:US
Practice Address - Phone:607-288-3441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010284133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered