Healthcare Provider Details

I. General information

NPI: 1043890767
Provider Name (Legal Business Name): ALISON P KUCICH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2021
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 WOODLAND DR S
FAIR HAVEN NJ
07704-3642
US

IV. Provider business mailing address

18 WOODLAND DR S
FAIR HAVEN NJ
07704-3642
US

V. Phone/Fax

Practice location:
  • Phone: 917-331-5665
  • Fax:
Mailing address:
  • Phone: 917-331-5665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: