Provider Demographics
NPI:1730784919
Name:WAEGELEIN, JEANETTE (RDN)
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:WAEGELEIN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 ROYAL CT UNIT 6201
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2614
Mailing Address - Country:US
Mailing Address - Phone:845-206-1503
Mailing Address - Fax:
Practice Address - Street 1:38C GROVE ST
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4669
Practice Address - Country:US
Practice Address - Phone:203-900-4416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010542133V00000X
CT1959133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered