Provider Demographics
NPI:1366072357
Name:NENNINGER, ROSEANNE (ND)
Entity type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:
Last Name:NENNINGER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 RANDALL AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1638
Mailing Address - Country:US
Mailing Address - Phone:631-834-2502
Mailing Address - Fax:
Practice Address - Street 1:115 RANDALL AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1638
Practice Address - Country:US
Practice Address - Phone:631-834-2502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3866133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered