Provider Demographics
NPI:1457864456
Name:DIETITIANS OF NORTHERN NEW YORK
Entity Type:Organization
Organization Name:DIETITIANS OF NORTHERN NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:315-486-6077
Mailing Address - Street 1:16358 STAR SCHOOL HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NY
Mailing Address - Zip Code:13634-3094
Mailing Address - Country:US
Mailing Address - Phone:315-486-6077
Mailing Address - Fax:
Practice Address - Street 1:312 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3614
Practice Address - Country:US
Practice Address - Phone:315-486-6077
Practice Address - Fax:315-486-6077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty