Provider Demographics
NPI:1962988543
Name:RICCARDI, RENA MARIE (MS, RD, CDE)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:MARIE
Last Name:RICCARDI
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:LAKE LINCOLNDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10541-5300
Mailing Address - Country:US
Mailing Address - Phone:914-772-1005
Mailing Address - Fax:914-556-6356
Practice Address - Street 1:255 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-4869
Practice Address - Country:US
Practice Address - Phone:914-772-1005
Practice Address - Fax:845-547-3357
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
724462133NN1002X, 133VN1006X
174H00000X, 311ZA0620X, 320600000X, 320900000X
NY7244622080B0002X
NY2170033872080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator
No2080B0002XAllopathic & Osteopathic PhysiciansPediatricsObesity Medicine
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
724462OtherCDR
21700387OtherNCBDE