Provider Demographics
NPI:1790461655
Name:NISANOV, MINDY MARLA (RD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:MARLA
Last Name:NISANOV
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 FAIRWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598
Mailing Address - Country:US
Mailing Address - Phone:917-828-7209
Mailing Address - Fax:
Practice Address - Street 1:536 FAIRWAY DRIVE
Practice Address - Street 2:
Practice Address - City:WOODMERE
Practice Address - State:NY
Practice Address - Zip Code:11598
Practice Address - Country:US
Practice Address - Phone:917-828-7209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered