MEDICARE: CHRISTINA FAHY RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	006979-1	NY

General Provider Information

NPI Number	:	1720445869
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA FAHY RD

Provider Business Mailing Address
First Line	:	2375 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306
Country	:	US
Telephone Number	:	347-559-1254
Fax Number	:

Provider Business Practice Location Address
First Line	:	2375 RICHMOND RD
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2352
Country	:	US
Telephone Number	:	347-559-1254
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2016
Last Update Date	:	01/20/2016

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