Provider Demographics
NPI:1497009377
Name:LUPOLI, MARY ALEXIS (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ALEXIS
Last Name:LUPOLI
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:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:SOUTH CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12482-0386
Mailing Address - Country:US
Mailing Address - Phone:518-821-7161
Mailing Address - Fax:
Practice Address - Street 1:159 JEFFERSON HTS
Practice Address - Street 2:SUITE D-303
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1237
Practice Address - Country:US
Practice Address - Phone:518-821-7161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY947105133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered