Provider Demographics
NPI:1750976908
Name:FUNG, KATY (MS, RD, CDN, CSO)
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:FUNG
Suffix:
Gender:F
Credentials:MS, RD, CDN, CSO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11047 63RD DR
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1407
Mailing Address - Country:US
Mailing Address - Phone:917-599-8493
Mailing Address - Fax:
Practice Address - Street 1:11047 63RD DR
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-1407
Practice Address - Country:US
Practice Address - Phone:917-599-8493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009530133N00000X
NY86072330133V00000X, 133VN1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered