Provider Demographics
NPI:1558038232
Name:UTICA NUTRITION SERVICES CERTIFIED DIETITIAN NUTRITIONIST
Entity Type:Organization
Organization Name:UTICA NUTRITION SERVICES CERTIFIED DIETITIAN NUTRITIONIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:CLEANNE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CDN
Authorized Official - Phone:315-922-3192
Mailing Address - Street 1:PO BOX 377
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0377
Mailing Address - Country:US
Mailing Address - Phone:315-922-3192
Mailing Address - Fax:
Practice Address - Street 1:2709 GENESEE ST STE 213
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-6222
Practice Address - Country:US
Practice Address - Phone:315-922-3192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty