Basic Information
Provider Information | |||||||||
NPI: | 1205029956 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANGELILLO | ||||||||
FirstName: | HEATHER | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD,CDN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRUNO | ||||||||
OtherFirstName: | HEATHER | ||||||||
OtherMiddleName: | A. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD, CDN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1000 ZECKENDORF BLVD | ||||||||
Address2: |   | ||||||||
City: | GARDEN CITY | ||||||||
State: | NY | ||||||||
PostalCode: | 115302133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5165426880 | ||||||||
FaxNumber: | 5165425556 | ||||||||
Practice Location | |||||||||
Address1: | 140-15 SANFORD AVE. | ||||||||
Address2: |   | ||||||||
City: | FLUSHING | ||||||||
State: | NY | ||||||||
PostalCode: | 11355 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7186706400 | ||||||||
FaxNumber: | 7186706479 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2007 | ||||||||
LastUpdateDate: | 12/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 006302 | NY | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.