Healthcare Provider Details

I. General information

NPI: 1346365087
Provider Name (Legal Business Name): MICHELE AVITABILE MS, RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 CROMWELL AVE
STATEN ISLAND NY
10304-3944
US

IV. Provider business mailing address

133 CONNECTICUT ST
STATEN ISLAND NY
10307-1519
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-8100
  • Fax: 718-667-6280
Mailing address:
  • Phone: 917-574-9398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number850647
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: