Healthcare Provider Details

I. General information

NPI: 1598069593
Provider Name (Legal Business Name): JULENE STASSOU MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2011
Last Update Date: 01/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 FRANKLIN TPKE SUITE 110
WALDWICK NJ
07463-1849
US

IV. Provider business mailing address

2041 EDWIN AVE
FORT LEE NJ
07024-2934
US

V. Phone/Fax

Practice location:
  • Phone: 201-612-5100
  • Fax:
Mailing address:
  • Phone: 201-947-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number867918
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: