Provider Demographics
NPI:1538768247
Name:URKEVICH, ROSE (RD, CDN)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:URKEVICH
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 1:65 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-9722
Mailing Address - Country:US
Mailing Address - Phone:518-867-7390
Mailing Address - Fax:
Practice Address - Street 1:65 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-9722
Practice Address - Country:US
Practice Address - Phone:518-867-7390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86077940133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered