Provider Demographics
NPI:1588443089
Name:CARFAGNO, JACQUELINE ANN MISCH (RD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN MISCH
Last Name:CARFAGNO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 W HIGH TER
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2241
Mailing Address - Country:US
Mailing Address - Phone:315-708-8737
Mailing Address - Fax:
Practice Address - Street 1:1205 W HIGH TER
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-2241
Practice Address - Country:US
Practice Address - Phone:315-708-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86118356133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered