Basic Information
| Provider Information | |||||||||
| NPI: | 1215168919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDLUST | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 759 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137949999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 759 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011991001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137944954 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 401960 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.