Provider Demographics
NPI:1710013339
Name:STOLLBERGER, JOAN (RD, CDE)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:STOLLBERGER
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 FOX HILL DR
Mailing Address - Street 2:
Mailing Address - City:CALVERTON
Mailing Address - State:NY
Mailing Address - Zip Code:11933-9503
Mailing Address - Country:US
Mailing Address - Phone:631-979-9512
Mailing Address - Fax:631-979-9512
Practice Address - Street 1:202 FOX HILL DR
Practice Address - Street 2:
Practice Address - City:CALVERTON
Practice Address - State:NY
Practice Address - Zip Code:11933-9503
Practice Address - Country:US
Practice Address - Phone:631-979-9512
Practice Address - Fax:631-979-9512
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003655-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2211060OtherOXFORD
NYS01991Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY