Healthcare Provider Details

I. General information

NPI: 1053316539
Provider Name (Legal Business Name): KUSUM L KANSAL RD,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 LAFAYETTE AVE
HAWTHORNE NJ
07506-2506
US

IV. Provider business mailing address

28 AGAWAM DR
WAYNE NJ
07470-2060
US

V. Phone/Fax

Practice location:
  • Phone: 973-460-7560
  • Fax: 862-239-6059
Mailing address:
  • Phone: 973-460-7560
  • Fax: 973-696-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number586681
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: