Healthcare Provider Details

I. General information

NPI: 1275070765
Provider Name (Legal Business Name): MALGORZATA ROKOSZAK RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 LANSING ST
STATEN ISLAND NY
10305-4307
US

IV. Provider business mailing address

97 LANSING ST
STATEN ISLAND NY
10305-4307
US

V. Phone/Fax

Practice location:
  • Phone: 347-733-3629
  • Fax:
Mailing address:
  • Phone: 347-733-3629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008452-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: