Provider Demographics
NPI:1629373311
Name:MALDONADO, MILDRED E (MSA,RDE,CDN)
Entity Type:Individual
Prefix:
First Name:MILDRED
Middle Name:E
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:MSA,RDE,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 SELWYN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-7626
Mailing Address - Country:US
Mailing Address - Phone:718-960-1010
Mailing Address - Fax:718-960-1011
Practice Address - Street 1:1650 SELWYN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7626
Practice Address - Country:US
Practice Address - Phone:718-960-1010
Practice Address - Fax:718-960-1011
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004275133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist