Healthcare Provider Details

I. General information

NPI: 1982848537
Provider Name (Legal Business Name): EVELYN DURAN - PONCE RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 SMITHTOWN BYP 103
SMITHTOWN NY
11787-5020
US

IV. Provider business mailing address

732 SMITHTOWN BYP STE 103
SMITHTOWN NY
11787-5020
US

V. Phone/Fax

Practice location:
  • Phone: 631-265-5545
  • Fax: 631-265-8042
Mailing address:
  • Phone: 631-265-5545
  • Fax: 631-265-8042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number005188-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number855320
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: