Provider Demographics
NPI:1811488240
Name:FUNCTIONAL NUTRITION OF WESTERN NEW YORK, PLLC
Entity type:Organization
Organization Name:FUNCTIONAL NUTRITION OF WESTERN NEW YORK, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED DIETITIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, CDN
Authorized Official - Phone:716-531-5207
Mailing Address - Street 1:352 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14174-1404
Mailing Address - Country:US
Mailing Address - Phone:716-531-5207
Mailing Address - Fax:
Practice Address - Street 1:352 BRENTWOOD DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:NY
Practice Address - Zip Code:14174-1404
Practice Address - Country:US
Practice Address - Phone:716-531-5207
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service