Basic Information
| Provider Information | |||||||||
| NPI: | 1679559561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BENCIVENGO | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MPH RD CDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 WESTCHESTER AVE STE N715 | ||||||||
| Address2: | |||||||||
| City: | RYE BROOK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105731376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9146075730 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 WESTCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106042901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148314154 | ||||||||
| FaxNumber: | 9144571526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 01/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 005178-1 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NY | MEDICAID |