Provider Demographics
NPI:1750608683
Name:GANDOLFO, NANCY C (RD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:C
Last Name:GANDOLFO
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 1:56 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1253
Mailing Address - Country:US
Mailing Address - Phone:203-709-3529
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-3529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-03
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000235133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist