Provider Demographics
NPI:1073749297
Name:DISTINGUISHED DIETITIAN NUTRITIONIST PLLC
Entity Type:Organization
Organization Name:DISTINGUISHED DIETITIAN NUTRITIONIST PLLC
Other - Org Name:FEED THE SOUL NUTRITION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERRY-GARNSEY
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDE
Authorized Official - Phone:315-955-9998
Mailing Address - Street 1:312 SHERMAN STREET
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-955-9998
Mailing Address - Fax:315-782-0386
Practice Address - Street 1:312 SHERMAN STREET
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:315-955-9998
Practice Address - Fax:315-782-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-02
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005592133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty