Provider Demographics
NPI:1881794451
Name:RANDAZZO, JOANN M (RD, CDN)
Entity type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:M
Last Name:RANDAZZO
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 1:140 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4629
Mailing Address - Country:US
Mailing Address - Phone:631-806-6005
Mailing Address - Fax:631-789-0861
Practice Address - Street 1:2115 UNION BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8017
Practice Address - Country:US
Practice Address - Phone:631-991-8291
Practice Address - Fax:631-789-0861
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006124133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered