Provider Demographics
NPI:1700524469
Name:MINICUCCI, OLIVIA (MS, RD)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:MINICUCCI
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:NEW CANAAN
Mailing Address - State:CT
Mailing Address - Zip Code:06840-5325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2198 GREENVIEW COVE DR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-7750
Practice Address - Country:US
Practice Address - Phone:514-299-3394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND11008133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered