Provider Demographics
NPI:1619386364
Name:MATTINA, CAITLIN ALICE (RD)
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ALICE
Last Name:MATTINA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:ALICE
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:115 E 34TH ST
Mailing Address - Street 2:19J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-4629
Mailing Address - Country:US
Mailing Address - Phone:585-704-0875
Mailing Address - Fax:
Practice Address - Street 1:115 E 34TH ST
Practice Address - Street 2:19J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4629
Practice Address - Country:US
Practice Address - Phone:585-704-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered