Provider Demographics
NPI:1790382877
Name:DECECCO, JULIA NICOLE (RD)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:NICOLE
Last Name:DECECCO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-3531
Mailing Address - Country:US
Mailing Address - Phone:267-566-9735
Mailing Address - Fax:
Practice Address - Street 1:608 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-3531
Practice Address - Country:US
Practice Address - Phone:267-566-9735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86110900133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86110900OtherCOMMISSION ON DIETETIC REGISTRATION