Provider Demographics
NPI:1689630824
Name:KRULY, SOPHIA (RD,CDN,CDE)
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:KRULY
Suffix:
Gender:F
Credentials:RD,CDN,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:135 GRANT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-1604
Practice Address - Country:US
Practice Address - Phone:716-881-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003464163WN1003X
NY003464-1133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No163WN1003XNursing Service ProvidersRegistered NurseNutrition Support
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA8355Medicare ID - Type Unspecified