Provider Demographics
NPI:1720691462
Name:AGOULNIK, DOROTHY
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:AGOULNIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DASHA
Other - Middle Name:
Other - Last Name:AGOULNIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:202 S PARKER ST UNIT 743
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-2603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:202 S PARKER ST UNIT 743
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2603
Practice Address - Country:US
Practice Address - Phone:978-394-0049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86167330133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered