Provider Demographics
NPI:1649748203
Name:DACQUISTO, GINNY (RD, CD)
Entity Type:Individual
Prefix:
First Name:GINNY
Middle Name:
Last Name:DACQUISTO
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 LILY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066
Mailing Address - Country:US
Mailing Address - Phone:262-443-1453
Mailing Address - Fax:
Practice Address - Street 1:1134 LILY RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066
Practice Address - Country:US
Practice Address - Phone:262-443-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86040888133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered