MEDICARE: ALEXANDRA REVERENDO MPH, IBCLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian		NJ

General Provider Information

NPI Number	:	1790635431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRA REVERENDO MPH, IBCLC

Provider Business Mailing Address
First Line	:	PO BOX 7
Second Line	:
City	:	MIDDLETOWN
State	:	NJ
Zip	:	07748-0007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 PALMER CT
Second Line	:
City	:	HOLMDEL
State	:	NJ
Zip	:	07733-1022
Country	:	US
Telephone Number	:	732-771-5269
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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