Provider Demographics
NPI:1619514783
Name:HALLISSEY, NICOLE LYN (RDN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYN
Last Name:HALLISSEY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 E END AVE APT 4D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-7980
Mailing Address - Country:US
Mailing Address - Phone:201-264-2251
Mailing Address - Fax:347-348-0734
Practice Address - Street 1:7 BROOK ST
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-1103
Practice Address - Country:US
Practice Address - Phone:201-264-2251
Practice Address - Fax:347-348-0734
Is Sole Proprietor?:No
Enumeration Date:2019-12-07
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered