Provider Demographics
NPI:1902008501
Name:ISENBERG, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:ISENBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:77 W BARNEY ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1040
Practice Address - Country:US
Practice Address - Phone:315-287-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184366133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY184366OtherREGISTRATION NUMBER