Provider Demographics
NPI:1568839421
Name:PETROCELLI, NICOLE ROSE (RD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:PETROCELLI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ROSE
Other - Last Name:MARCIANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:24 HERITAGE LN N
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-3316
Mailing Address - Country:US
Mailing Address - Phone:631-327-7934
Mailing Address - Fax:
Practice Address - Street 1:24 HERITAGE LN N
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-3316
Practice Address - Country:US
Practice Address - Phone:631-327-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-27
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1057815133VN1006X, 133VN1004X, 133VN1005X, 133N00000X, 133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education