Provider Demographics
NPI:1124247325
Name:ROBACZYNSKI, CHERYL LEA (RD, CDN)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:LEA
Last Name:ROBACZYNSKI
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1645
Mailing Address - Country:US
Mailing Address - Phone:203-378-8754
Mailing Address - Fax:203-378-8754
Practice Address - Street 1:111 GOOSE LN
Practice Address - Street 2:YNHH SHORELINE MEDICAL CENTER
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-5101
Practice Address - Country:US
Practice Address - Phone:203-453-7199
Practice Address - Fax:203-688-2141
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000662133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT661901OtherCREDENTIAL FOR RD
CTC02658Medicare ID - Type UnspecifiedYNHH MEDICARE NUMBER