Healthcare Provider Details

I. General information

NPI: 1629373311
Provider Name (Legal Business Name): MILDRED E. MALDONADO MSA.,RDE.,CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 SELWYN AVE
BRONX NY
10457-7626
US

IV. Provider business mailing address

1650 SELWYN AVE
BRONX NY
10457-7626
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-1010
  • Fax: 718-960-1011
Mailing address:
  • Phone: 718-960-1010
  • Fax: 718-960-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number004275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: