Healthcare Provider Details

I. General information

NPI: 1780041053
Provider Name (Legal Business Name): ANNA KHESIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2016
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 RIVER RD APT 103
NORTH BERGEN NJ
07047-7204
US

IV. Provider business mailing address

8100 RIVER RD APT 103
NORTH BERGEN NJ
07047-7204
US

V. Phone/Fax

Practice location:
  • Phone: 516-445-6614
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86018772
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: