=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245808104
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BROOKE BUCINELL RD,CDCES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2021
-----------------------------------------------------
Last Update Date | 02/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 SHAKER RD STE 201
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12204-1030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-471-3636
-----------------------------------------------------
Fax | 518-471-3668
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 14890
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12212-4890
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 86076678
-----------------------------------------------------
License Number State |
-----------------------------------------------------