Provider Demographics
NPI:1316426646
Name:BERGOMI, ELENA JOY (RDN, LDN)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:JOY
Last Name:BERGOMI
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 ALDIE ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-1307
Mailing Address - Country:US
Mailing Address - Phone:914-539-5412
Mailing Address - Fax:
Practice Address - Street 1:51 ALDIE ST UNIT 1
Practice Address - Street 2:
Practice Address - City:ALLSTON
Practice Address - State:MA
Practice Address - Zip Code:02134-1307
Practice Address - Country:US
Practice Address - Phone:914-539-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4590-NU-NU133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered