=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285727073
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN FULGIONE RDN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2006
-----------------------------------------------------
Last Update Date | 10/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 61 CONKLIN AVE
-----------------------------------------------------
City | TAPPAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10983-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-535-1725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61 CONKLIN AVE
-----------------------------------------------------
City | TAPPAN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10983-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-535-1725
-----------------------------------------------------
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 | 002870-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------