Provider Demographics
NPI:1134557556
Name:NISTICO, CARYN (MS,RDN)
Entity type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:NISTICO
Suffix:
Gender:F
Credentials:MS,RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4522
Mailing Address - Country:US
Mailing Address - Phone:631-425-1578
Mailing Address - Fax:631-425-1578
Practice Address - Street 1:153 BEVERLY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4522
Practice Address - Country:US
Practice Address - Phone:631-425-1578
Practice Address - Fax:631-425-1578
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-22
Last Update Date:2013-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002667-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered