Provider Demographics
NPI:1801651591
Name:DESTEFANO, NICOLE ROSE (RD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:DESTEFANO
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 1:55 LEXINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-1607
Mailing Address - Country:US
Mailing Address - Phone:845-926-7592
Mailing Address - Fax:
Practice Address - Street 1:55 LEXINGTON WAY
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-1607
Practice Address - Country:US
Practice Address - Phone:845-926-7592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered