Provider Demographics
NPI:1578327458
Name:FITZGEREL, EKATERINA
Entity Type:Individual
Prefix:
First Name:EKATERINA
Middle Name:
Last Name:FITZGEREL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 ISLE VERDE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-1710
Mailing Address - Country:US
Mailing Address - Phone:561-875-4428
Mailing Address - Fax:
Practice Address - Street 1:105 ISLE VERDE WAY
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33418-1710
Practice Address - Country:US
Practice Address - Phone:561-875-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11514133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty