Healthcare Provider Details

I. General information

NPI: 1962988543
Provider Name (Legal Business Name): RENA MARIE RICCARDI MS, RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 LAFAYETTE AVE
SUFFERN NY
10901-4869
US

IV. Provider business mailing address

4 JUNIPER DR
LAKE LINCOLNDALE NY
10541-5300
US

V. Phone/Fax

Practice location:
  • Phone: 914-772-1005
  • Fax: 845-547-3357
Mailing address:
  • Phone: 914-772-1005
  • Fax: 914-556-6356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number724462
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License Number724462
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number217003387
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number724462
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: