Healthcare Provider Details

I. General information

NPI: 1568839421
Provider Name (Legal Business Name): NICOLE ROSE PETROCELLI R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ROSE MARCIANTE R.D.

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HERITAGE LN N
MILLER PLACE NY
11764-3316
US

IV. Provider business mailing address

24 HERITAGE LN N
MILLER PLACE NY
11764-3316
US

V. Phone/Fax

Practice location:
  • Phone: 631-327-7934
  • Fax:
Mailing address:
  • Phone: 631-327-7934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1057815
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1057815
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1057815
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number1057815
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1057815
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1057815
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: