Healthcare Provider Details

I. General information

NPI: 1154876605
Provider Name (Legal Business Name): MARIELLE ZUCCOLO RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 TRACY CREEK RD
VESTAL NY
13850-1062
US

IV. Provider business mailing address

249 GLENWOOD RD
BINGHAMTON NY
13905-1603
US

V. Phone/Fax

Practice location:
  • Phone: 607-786-9063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006951-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: