Basic Information
| Provider Information | |||||||||
| NPI: | 1538742663 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | GARIANDO | ||||||||
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| Credential: | RD, CDN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CHAN | ||||||||
| OtherFirstName: | OLIVIA | ||||||||
| OtherMiddleName: | GARIANDO | ||||||||
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| OtherCredential: | RD, CDN | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 90 BLUESPRUCE RD | ||||||||
| Address2: | |||||||||
| City: | LEVITTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117561946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165212914 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1901 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100297494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124236262 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2021 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 835228 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.