Provider Demographics
NPI:1629730908
Name:SHERRY, MARISA (MS, RD, CDN, CEDRD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:SHERRY
Suffix:
Gender:F
Credentials:MS, RD, CDN, CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 BUCK RD
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-5553
Mailing Address - Country:US
Mailing Address - Phone:646-265-7708
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 904
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8120
Practice Address - Country:US
Practice Address - Phone:917-573-7003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010702133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered