Provider Demographics
NPI:1972809598
Name:AVASTHI, POONAM (RD,CDN)
Entity type:Individual
Prefix:MISS
First Name:POONAM
Middle Name:
Last Name:AVASTHI
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 CANDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-2826
Mailing Address - Country:US
Mailing Address - Phone:914-961-4717
Mailing Address - Fax:914-961-4717
Practice Address - Street 1:126 CANDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-2826
Practice Address - Country:US
Practice Address - Phone:914-961-4717
Practice Address - Fax:914-961-4717
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-28
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY943765133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY943765Medicare PIN