Provider Demographics
NPI:1942561444
Name:PUMILLO, LAURA JOAN
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:JOAN
Last Name:PUMILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:PUMILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, RD, CDN
Mailing Address - Street 1:76 BRADLEY RD
Mailing Address - Street 2:NY 10583
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-5722
Mailing Address - Country:US
Mailing Address - Phone:914-419-7604
Mailing Address - Fax:914-713-3064
Practice Address - Street 1:23 W 73RD ST
Practice Address - Street 2:SUITE 102
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3104
Practice Address - Country:US
Practice Address - Phone:914-419-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000918-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered