Provider Demographics
NPI:1417427600
Name:FARRELLY, KRISTEN BRONDE (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:BRONDE
Last Name:FARRELLY
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SEQUAMS LN W
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4524
Mailing Address - Country:US
Mailing Address - Phone:631-813-8560
Mailing Address - Fax:
Practice Address - Street 1:655 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-1314
Practice Address - Country:US
Practice Address - Phone:631-321-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009582133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered