Provider Demographics
NPI:1669847232
Name:NORMATOVA, IMMA (MS, RD, CLC)
Entity Type:Individual
Prefix:MRS
First Name:IMMA
Middle Name:
Last Name:NORMATOVA
Suffix:
Gender:F
Credentials:MS, RD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9822 63RD DR APT 2E
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2301
Mailing Address - Country:US
Mailing Address - Phone:718-532-6241
Mailing Address - Fax:
Practice Address - Street 1:9822 63RD DR APT 2E
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2301
Practice Address - Country:US
Practice Address - Phone:718-532-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1091516133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered