Provider Demographics
NPI:1932565488
Name:DECUNZO-TADDEO, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:DECUNZO-TADDEO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 NE 46TH ST
Mailing Address - Street 2:
Mailing Address - City:LIGHTHOUSE POINT
Mailing Address - State:FL
Mailing Address - Zip Code:33064-7258
Mailing Address - Country:US
Mailing Address - Phone:954-562-7767
Mailing Address - Fax:954-786-1742
Practice Address - Street 1:2521 NE 46TH ST
Practice Address - Street 2:
Practice Address - City:LIGHTHOUSE POINT
Practice Address - State:FL
Practice Address - Zip Code:33064-7258
Practice Address - Country:US
Practice Address - Phone:954-562-7767
Practice Address - Fax:954-786-1742
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-13
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2352133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered