Provider Demographics
NPI:1962733311
Name:CLEMENTONI, SALLY-ANN (RD)
Entity type:Individual
Prefix:
First Name:SALLY-ANN
Middle Name:
Last Name:CLEMENTONI
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 1:366 BURGHER AVE
Mailing Address - Street 2:APT 1A
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-2317
Mailing Address - Country:US
Mailing Address - Phone:347-934-3707
Mailing Address - Fax:
Practice Address - Street 1:366 BURGHER AVE
Practice Address - Street 2:APT 1A
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-2317
Practice Address - Country:US
Practice Address - Phone:347-934-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005343133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered