Provider Demographics
NPI:1821328758
Name:DEGNAN, MARY ELIZABETH (MS RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:DEGNAN
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 B HIGHLAND DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1235
Mailing Address - Country:US
Mailing Address - Phone:716-957-2285
Mailing Address - Fax:
Practice Address - Street 1:621 10TH ST
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1813
Practice Address - Country:US
Practice Address - Phone:716-278-4360
Practice Address - Fax:716-278-4266
Is Sole Proprietor?:No
Enumeration Date:2009-12-24
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007089133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8668370241Medicaid