Provider Demographics
NPI:1306968938
Name:EKUNNO-TABANSI, COMFORT N (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:
First Name:COMFORT
Middle Name:N
Last Name:EKUNNO-TABANSI
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 HILLSIDE TER
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4306
Mailing Address - Country:US
Mailing Address - Phone:201-491-9972
Mailing Address - Fax:973-324-2218
Practice Address - Street 1:170 NORWOOD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07106-2627
Practice Address - Country:US
Practice Address - Phone:201-491-9972
Practice Address - Fax:973-324-2218
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL927499133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097992U0YOtherRENDERING NUMBER
NJ097992Medicare PIN