Provider Demographics
NPI:1205226230
Name:ANDERSON, INGRID DAGMAR (RD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:DAGMAR
Last Name:ANDERSON
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 1:15 LONG LN
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12413-2509
Mailing Address - Country:US
Mailing Address - Phone:1518-533-0544
Mailing Address - Fax:
Practice Address - Street 1:15 LONG LN
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12413-2509
Practice Address - Country:US
Practice Address - Phone:1518-533-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86009617133V00000X
NY6009617133V00000X
NY009132-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered