Provider Demographics
NPI:1952421596
Name:FARRELL, MARIE WALLA (RD)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:WALLA
Last Name:FARRELL
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 1:80 MCCORMACK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE GEORGE
Mailing Address - State:NY
Mailing Address - Zip Code:12845-3425
Mailing Address - Country:US
Mailing Address - Phone:518-798-8032
Mailing Address - Fax:
Practice Address - Street 1:100 PARK ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-4413
Practice Address - Country:US
Practice Address - Phone:518-926-2612
Practice Address - Fax:518-926-6727
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001471-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001471-1Medicare ID - Type UnspecifiedCDN