Provider Demographics
NPI:1689778847
Name:FERGUSON, ALYSA (RD CDN)
Entity Type:Individual
Prefix:MS
First Name:ALYSA
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:RD CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 GRIFFING AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-3056
Mailing Address - Country:US
Mailing Address - Phone:631-727-7850
Mailing Address - Fax:631-727-7130
Practice Address - Street 1:82 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-4411
Practice Address - Country:US
Practice Address - Phone:631-854-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0061761133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
9622EMedicare PIN