Provider Demographics
NPI:1912651803
Name:PASQUARELLA, LEAH M (RD CDN)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:PASQUARELLA
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 1:35 ONTARIO ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFF STA
Mailing Address - State:NY
Mailing Address - Zip Code:11776-4345
Mailing Address - Country:US
Mailing Address - Phone:631-655-6205
Mailing Address - Fax:
Practice Address - Street 1:35 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:PORT JEFF STA
Practice Address - State:NY
Practice Address - Zip Code:11776-4345
Practice Address - Country:US
Practice Address - Phone:631-655-6205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006867-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty