Provider Demographics
NPI:1295827103
Name:HILLERY, LYNN P (MS RD CDN)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:P
Last Name:HILLERY
Suffix:
Gender:F
Credentials:MS RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 ANDREA LN
Mailing Address - Street 2:
Mailing Address - City:WEST SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11796-1515
Mailing Address - Country:US
Mailing Address - Phone:631-343-2024
Mailing Address - Fax:631-343-2024
Practice Address - Street 1:76 SOUTHAVEN AVE STE 2
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3745
Practice Address - Country:US
Practice Address - Phone:631-343-2024
Practice Address - Fax:631-343-2024
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006087-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400021956Medicare PIN