Healthcare Provider Details

I. General information

NPI: 1184338485
Provider Name (Legal Business Name): RACHEL CIPRIANO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RACHEL CANDELARIA RD

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 WINSTON DR N
PORT JEFFERSON NY
11777-1174
US

IV. Provider business mailing address

24 WINSTON DR N
PORT JEFFERSON NY
11777-1174
US

V. Phone/Fax

Practice location:
  • Phone: 631-512-2979
  • Fax:
Mailing address:
  • Phone: 631-512-2979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0875369
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: