Provider Demographics
NPI:1861254377
Name:LOPEZ, MIRANDA PAIGE (MS, RDN, CDN)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:PAIGE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MS, RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11742-2381
Mailing Address - Country:US
Mailing Address - Phone:631-741-8852
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1623
Practice Address - Country:US
Practice Address - Phone:631-662-7331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered