Healthcare Provider Details

I. General information

NPI: 1104738244
Provider Name (Legal Business Name): CONNIE S YUAN RDN, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7114 SUTTON PL APT 3F
FRESH MEADOWS NY
11365-4596
US

IV. Provider business mailing address

7114 SUTTON PL APT 3F
FRESH MEADOWS NY
11365-4596
US

V. Phone/Fax

Practice location:
  • Phone: 917-374-3586
  • Fax:
Mailing address:
  • Phone: 917-374-3586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: