Provider Demographics
NPI:1023431988
Name:LIPID (AKA)
Entity type:Organization
Organization Name:LIPID (AKA)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CONSULTING REG DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:
Authorized Official - Last Name:NISTICO
Authorized Official - Suffix:
Authorized Official - Credentials:MS,RDN,CDN
Authorized Official - Phone:631-425-1578
Mailing Address - Street 1:153 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4522
Mailing Address - Country:US
Mailing Address - Phone:631-425-1578
Mailing Address - Fax:631-425-1578
Practice Address - Street 1:153 BEVERLY RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-4522
Practice Address - Country:US
Practice Address - Phone:631-425-1578
Practice Address - Fax:631-425-1578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002667-1133NN1002X, 133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Multi-Specialty