Provider Demographics
NPI:1437495876
Name:PENASSO, DEBRA (RD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:PENASSO
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 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1412
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:200 LAKE ST
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-5243
Practice Address - Country:US
Practice Address - Phone:845-565-8022
Practice Address - Fax:845-565-6349
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
862415OtherDIETETIC REGISTRATION