Healthcare Provider Details

I. General information

NPI: 1740307537
Provider Name (Legal Business Name): HAZEL ALLISON THOMAS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5018 AVENUE D
BROOKLYN NY
11203-5906
US

IV. Provider business mailing address

11022 198TH ST
SAINT ALBANS NY
11412-1722
US

V. Phone/Fax

Practice location:
  • Phone: 718-451-2800
  • Fax: 718-451-2804
Mailing address:
  • Phone: 718-465-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number716482
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: