Provider Demographics
NPI:1417293218
Name:MADISON, ELIZABETH MARIE (MA, RDN, CDN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:MARIE
Last Name:MADISON
Suffix:
Gender:F
Credentials:MA, RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22919 MERRICK BLVD # 226
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-2108
Mailing Address - Country:US
Mailing Address - Phone:855-958-9958
Mailing Address - Fax:855-947-3783
Practice Address - Street 1:133-33 BROOKVILLE BOULEVARD
Practice Address - Street 2:SUITE 229C
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422
Practice Address - Country:US
Practice Address - Phone:855-958-9958
Practice Address - Fax:855-947-3783
Is Sole Proprietor?:No
Enumeration Date:2012-12-25
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008005133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered