Provider Demographics
NPI:1043044746
Name:DE LA CRUZ, NICOLAS (MS, RDN, CDN)
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:M
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 1:1276 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-3467
Mailing Address - Country:US
Mailing Address - Phone:718-992-7669
Mailing Address - Fax:
Practice Address - Street 1:199 MOUNT EDEN PKWY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-7703
Practice Address - Country:US
Practice Address - Phone:718-992-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-27
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009963133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered