Provider Demographics
NPI:1568069870
Name:SARRA, STEPHANIE (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SARRA
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16036 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-1905
Mailing Address - Country:US
Mailing Address - Phone:646-235-8577
Mailing Address - Fax:
Practice Address - Street 1:16036 12TH AVE
Practice Address - Street 2:
Practice Address - City:WHITESTONE
Practice Address - State:NY
Practice Address - Zip Code:11357-1905
Practice Address - Country:US
Practice Address - Phone:646-235-8577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009735-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty