Provider Demographics
NPI:1700454469
Name:CUSTODIO-LUMSDEN, CHRISTIE LAUREN (PHD, MS, RD, CDN)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIE
Middle Name:LAUREN
Last Name:CUSTODIO-LUMSDEN
Suffix:
Gender:F
Credentials:PHD, MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3927
Mailing Address - Country:US
Mailing Address - Phone:516-991-5817
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST PH 7-322
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-342-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007380133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1014411OtherCOMMISSION ON DIETETIC REGISTRATION ID
007380OtherNEW YORK STATE DIETETICS-NUTRITION LICENSE/CERTIFICATION ID