Provider Demographics
NPI:1790161123
Name:PAIGE, MYRNA (MS, RD, CDE, BC-ADM)
Entity Type:Individual
Prefix:
First Name:MYRNA
Middle Name:
Last Name:PAIGE
Suffix:
Gender:F
Credentials:MS, RD, CDE, BC-ADM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 SKYTOP LN
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-1812
Mailing Address - Country:US
Mailing Address - Phone:585-385-1742
Mailing Address - Fax:585-273-1288
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX 693
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-2901
Practice Address - Fax:585-273-1288
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000845-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered