Provider Demographics
NPI:1033457668
Name:NORRIS, TABITHA LYNN (RD)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:LYNN
Last Name:NORRIS
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 1:716 WILTON GANSEVOORT RD
Mailing Address - Street 2:
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1242
Mailing Address - Country:US
Mailing Address - Phone:518-209-4292
Mailing Address - Fax:
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-6871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1015496133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered