Provider Demographics
NPI:1699406546
Name:RANDAZZO, NICOLE MARIE (RDN, CDN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:RANDAZZO
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 PLUM TREE RD W
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6046
Mailing Address - Country:US
Mailing Address - Phone:516-712-7349
Mailing Address - Fax:
Practice Address - Street 1:969 PLUM TREE RD W
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-6046
Practice Address - Country:US
Practice Address - Phone:516-712-7349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009921-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered