Provider Demographics
NPI:1679671564
Name:BONVENTRE, JEANNETTE M (RD, CDN)
Entity Type:Individual
Prefix:MS
First Name:JEANNETTE
Middle Name:M
Last Name:BONVENTRE
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:MRS
Other - First Name:JEANNETTE
Other - Middle Name:M
Other - Last Name:FRABIZIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, CDN
Mailing Address - Street 1:84 BAY RD
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11719-9746
Mailing Address - Country:US
Mailing Address - Phone:631-803-0947
Mailing Address - Fax:
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-548-6407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006215-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered