Provider Demographics
NPI:1780348383
Name:BARTOLILLO, GRACE MAE (RD, CDN)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:MAE
Last Name:BARTOLILLO
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TITUS PL
Mailing Address - Street 2:
Mailing Address - City:WALTON
Mailing Address - State:NY
Mailing Address - Zip Code:13856-1455
Mailing Address - Country:US
Mailing Address - Phone:607-865-2159
Mailing Address - Fax:
Practice Address - Street 1:2 TITUS PL
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1455
Practice Address - Country:US
Practice Address - Phone:607-865-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY928918133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered