Provider Demographics
NPI:1770171191
Name:DECELLES, BROOKE ANN MARIE (MS, RD, CDN)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANN MARIE
Last Name:DECELLES
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:MRS
Other - First Name:BROOKE
Other - Middle Name:ANN MARIE
Other - Last Name:DECELLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:200 MARKET STREET
Mailing Address - Street 2:STE 5 PMB 112
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1217
Mailing Address - Country:US
Mailing Address - Phone:315-528-4711
Mailing Address - Fax:
Practice Address - Street 1:200 MARKET STREET
Practice Address - Street 2:STE 5 PMB 112
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-1217
Practice Address - Country:US
Practice Address - Phone:315-528-4711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01031301133V00000X
PADN007980133V00000X
NY010313-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered