Provider Demographics
NPI:1891247607
Name:AMMIRATI, MARYROSE (RD, CDN, CLC)
Entity type:Individual
Prefix:
First Name:MARYROSE
Middle Name:
Last Name:AMMIRATI
Suffix:
Gender:F
Credentials:RD, CDN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 OAK NECK ROAD
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795
Mailing Address - Country:US
Mailing Address - Phone:631-987-8915
Mailing Address - Fax:
Practice Address - Street 1:2 DUBON CT
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-1031
Practice Address - Country:US
Practice Address - Phone:631-210-6362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-27
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321986174N00000X
NY007859-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN