Provider Demographics
NPI:1508887399
Name:KONEZNY, MARILYN (RD CDE)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:KONEZNY
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 RIDGEWAY AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4296
Mailing Address - Country:US
Mailing Address - Phone:585-368-4560
Mailing Address - Fax:585-368-4565
Practice Address - Street 1:2655 RIDGEWAY AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-368-4560
Practice Address - Fax:585-368-4565
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002741133V00000X
CDR497643133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00330263OtherMEDICARE RAILROAD
NYRB8664-GROUP BA0017Medicare PIN
NYP00330263OtherMEDICARE RAILROAD
P46163Medicare UPIN