Provider Demographics
NPI:1326228933
Name:NOONAN, MARY K
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:NOONAN
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 1:62 HACKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1718
Mailing Address - Country:US
Mailing Address - Phone:518-434-2244
Mailing Address - Fax:518-434-4659
Practice Address - Street 1:62 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12209-1718
Practice Address - Country:US
Practice Address - Phone:518-434-2244
Practice Address - Fax:518-434-4659
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002347133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal