Healthcare Provider Details

I. General information

NPI: 1689630824
Provider Name (Legal Business Name): SOPHIA KRULY RD,CDN,CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 GRANT ST
BUFFALO NY
14213-1604
US

IV. Provider business mailing address

908 NIAGARA FALLS BLVD SUITE 208
NORTH TONAWANDA NY
14120-2019
US

V. Phone/Fax

Practice location:
  • Phone: 716-881-4300
  • Fax:
Mailing address:
  • Phone: 716-692-3302
  • Fax: 716-692-4342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN1003X
TaxonomyNutrition Support Registered Nurse
License Number003464
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number003464-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: