Healthcare Provider Details

I. General information

NPI: 1649360520
Provider Name (Legal Business Name): STEPHANIE ANN BERGAMINI RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WESTAGE BUSINESS CTR DR SUITE 119
FISHKILL NY
12524-2264
US

IV. Provider business mailing address

85 NEWFIELD AVE SUITE B
EDISON NJ
08837-3816
US

V. Phone/Fax

Practice location:
  • Phone: 845-897-2905
  • Fax: 845-897-2908
Mailing address:
  • Phone: 732-346-1333
  • Fax: 732-346-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number863831
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: