Provider Demographics
NPI:1306230461
Name:HUSSERL, CARLYE
Entity Type:Individual
Prefix:
First Name:CARLYE
Middle Name:
Last Name:HUSSERL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 KNIGHT STREET
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572
Mailing Address - Country:US
Mailing Address - Phone:914-474-0345
Mailing Address - Fax:
Practice Address - Street 1:3530 KNIGHT ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-4616
Practice Address - Country:US
Practice Address - Phone:914-474-0345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered