Provider Demographics
NPI:1598704249
Name:ROOSA, WENDY M (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:M
Last Name:ROOSA
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 KATRINA FALLS RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:NY
Mailing Address - Zip Code:12775-6007
Mailing Address - Country:US
Mailing Address - Phone:845-243-1679
Mailing Address - Fax:
Practice Address - Street 1:35 BARBAROSA LN
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1221
Practice Address - Country:US
Practice Address - Phone:845-626-3445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered