Provider Demographics
NPI:1447622865
Name:WONG, MABLE (RD, CDN)
Entity type:Individual
Prefix:
First Name:MABLE
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DANVILLE DR
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-2802
Mailing Address - Country:US
Mailing Address - Phone:917-678-2550
Mailing Address - Fax:
Practice Address - Street 1:2 DANVILLE DR
Practice Address - Street 2:
Practice Address - City:GREENLAWN
Practice Address - State:NY
Practice Address - Zip Code:11740-2802
Practice Address - Country:US
Practice Address - Phone:917-678-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-25
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007930-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered