Provider Demographics
NPI:1285036731
Name:FRUCHT, MIRIAM (MS, RD, CDN)
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:
Last Name:FRUCHT
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10240 67TH RD
Mailing Address - Street 2:APT 1T
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2663
Mailing Address - Country:US
Mailing Address - Phone:347-742-7658
Mailing Address - Fax:
Practice Address - Street 1:10240 67TH RD
Practice Address - Street 2:APT 1T
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2663
Practice Address - Country:US
Practice Address - Phone:347-742-7658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1023258133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered