Provider Demographics
NPI:1245808104
Name:BUCINELL, BROOKE (RD,CDCES)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:BUCINELL
Suffix:
Gender:F
Credentials:RD,CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:63 SHAKER RD STE 201
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1030
Practice Address - Country:US
Practice Address - Phone:518-471-3636
Practice Address - Fax:518-471-3668
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86076678133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered