Provider Demographics
NPI:1861946246
Name:FONTANELLI, JESSICA (RD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FONTANELLI
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 1:2125 RIVER RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:NISKAYUNA
Mailing Address - State:NY
Mailing Address - Zip Code:12309-1135
Mailing Address - Country:US
Mailing Address - Phone:518-243-1313
Mailing Address - Fax:518-831-7007
Practice Address - Street 1:2125 RIVER RD
Practice Address - Street 2:SUITE 302
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-1135
Practice Address - Country:US
Practice Address - Phone:518-243-1313
Practice Address - Fax:518-831-7007
Is Sole Proprietor?:No
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007418133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered