Provider Demographics
NPI:1457481293
Name:WISOFF, LAILINA S (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAILINA
Middle Name:S
Last Name:WISOFF
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 1:6714 73RD PL # 2
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2527
Mailing Address - Country:US
Mailing Address - Phone:303-249-8061
Mailing Address - Fax:
Practice Address - Street 1:6714 73RD PL # 2
Practice Address - Street 2:
Practice Address - City:MIDDLE VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11379-2527
Practice Address - Country:US
Practice Address - Phone:303-249-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
HI230-LD133V00000X
NY011624-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC017028Medicare PIN