Provider Demographics
NPI:1083912604
Name:ETTEDGUI, REBECCA (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:ETTEDGUI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 W 66TH ST
Mailing Address - Street 2:18C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-6206
Mailing Address - Country:US
Mailing Address - Phone:646-662-7233
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-06
Last Update Date:2011-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007135133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered