Provider Demographics
NPI:1952610511
Name:KRSULICH, JOANNA (MS, RD)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:KRSULICH
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:JOANNA
Other - Middle Name:
Other - Last Name:KRSULICH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:44 HUNGERFORD RD
Mailing Address - Street 2:
Mailing Address - City:BRIARCLIFF
Mailing Address - State:NY
Mailing Address - Zip Code:10510-1310
Mailing Address - Country:US
Mailing Address - Phone:914-762-1662
Mailing Address - Fax:
Practice Address - Street 1:1055 SAW MILL RIVER RD
Practice Address - Street 2:
Practice Address - City:ARDSLEY
Practice Address - State:NY
Practice Address - Zip Code:10502-1045
Practice Address - Country:US
Practice Address - Phone:914-886-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-30
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005352-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered