Healthcare Provider Details

I. General information

NPI: 1306968938
Provider Name (Legal Business Name): COMFORT N EKUNNO-TABANSI REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 11/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 NORWOOD ST
NEWARK NJ
07106-2627
US

IV. Provider business mailing address

540 HILLSIDE TER
WEST ORANGE NJ
07052-4306
US

V. Phone/Fax

Practice location:
  • Phone: 201-491-9972
  • Fax: 973-324-2218
Mailing address:
  • Phone: 201-491-9972
  • Fax: 973-324-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number927499
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: