Provider Demographics
NPI:1114673332
Name:VANNORTWICK, MARY T (DCN, RDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:T
Last Name:VANNORTWICK
Suffix:
Gender:F
Credentials:DCN, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SIA MEDICAL PC
Mailing Address - Street 2:176 E. 71ST STREET, #10B
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5159
Mailing Address - Country:US
Mailing Address - Phone:201-778-1126
Mailing Address - Fax:
Practice Address - Street 1:FLYTE MEDICAL PC
Practice Address - Street 2:69 GROVE STREET
Practice Address - City:NEW CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06840-5325
Practice Address - Country:US
Practice Address - Phone:844-359-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management