Provider Demographics
NPI:1619603941
Name:RAPHAEL, GEROMINA (MS, RD, LD/N, CLC)
Entity Type:Individual
Prefix:
First Name:GEROMINA
Middle Name:
Last Name:RAPHAEL
Suffix:
Gender:F
Credentials:MS, RD, LD/N, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 NW 68TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-7517
Mailing Address - Country:US
Mailing Address - Phone:954-394-4459
Mailing Address - Fax:
Practice Address - Street 1:406 NW 68TH AVE APT 104
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-7517
Practice Address - Country:US
Practice Address - Phone:954-394-4459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN