Provider Demographics
NPI:1679559561
Name:BENCIVENGO, ANGELA (MPH RD CDN)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:BENCIVENGO
Suffix:
Gender:F
Credentials:MPH RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 WESTCHESTER AVE STE N715
Mailing Address - Street 2:
Mailing Address - City:RYE BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:10573-1376
Mailing Address - Country:US
Mailing Address - Phone:914-607-5730
Mailing Address - Fax:
Practice Address - Street 1:210 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10604-2901
Practice Address - Country:US
Practice Address - Phone:914-831-4154
Practice Address - Fax:914-457-1526
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005178-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid