Provider Demographics
NPI:1629359518
Name:THIPPESWAMI, PRAFULLA (RD)
Entity Type:Individual
Prefix:
First Name:PRAFULLA
Middle Name:
Last Name:THIPPESWAMI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 PEMBROKE RD
Mailing Address - Street 2:#42
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06811-3075
Mailing Address - Country:US
Mailing Address - Phone:203-312-0879
Mailing Address - Fax:
Practice Address - Street 1:136 PEMBROKE RD
Practice Address - Street 2:#42
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06811-3075
Practice Address - Country:US
Practice Address - Phone:203-312-0879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT706642133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered