Provider Demographics
NPI:1154404705
Name:PETROCCIONE, DARLENE RENEE (RD, CDN)
Entity type:Individual
Prefix:MRS
First Name:DARLENE
Middle Name:RENEE
Last Name:PETROCCIONE
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:640 BELLE TERRE RD
Mailing Address - Street 2:BUILDING E
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1936
Mailing Address - Country:US
Mailing Address - Phone:631-987-4006
Mailing Address - Fax:631-828-1138
Practice Address - Street 1:640 BELLE TERRE RD
Practice Address - Street 2:BUILDING E
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1936
Practice Address - Country:US
Practice Address - Phone:631-987-4006
Practice Address - Fax:631-828-1138
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY5320-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY09Q821Medicare ID - Type Unspecified