Provider Demographics
NPI:1285820829
Name:COOK, KACIE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:MARIE
Last Name:COOK
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 1:5150 FIELDSTONE TRL
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-8244
Mailing Address - Country:US
Mailing Address - Phone:585-412-6062
Mailing Address - Fax:
Practice Address - Street 1:46 PRINCE ST
Practice Address - Street 2:SUITE 3001
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1023
Practice Address - Country:US
Practice Address - Phone:585-530-2050
Practice Address - Fax:585-530-2398
Is Sole Proprietor?:No
Enumeration Date:2007-09-18
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY979836133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400017534Medicare PIN