Healthcare Provider Details

I. General information

NPI: 1871775171
Provider Name (Legal Business Name): TATIANA KIDANOV MS,RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 AVE P
BROOKLYN NY
11229
US

IV. Provider business mailing address

36 BORMAN AVE
STATEN ISLAND NY
10314
US

V. Phone/Fax

Practice location:
  • Phone: 718-648-2162
  • Fax:
Mailing address:
  • Phone: 917-721-4494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number006762
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: