Healthcare Provider Details

I. General information

NPI: 1497947063
Provider Name (Legal Business Name): JENNIFER TAVERAS R.D.,CDN,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5514 MAIN ST
FLUSHING NY
11355-5058
US

IV. Provider business mailing address

829 PLAINFIELD LN
VALLEY STREAM NY
11581-3608
US

V. Phone/Fax

Practice location:
  • Phone: 516-510-5769
  • Fax:
Mailing address:
  • Phone: 516-510-5769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2011-0516
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005680-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: