Healthcare Provider Details

I. General information

NPI: 1275040842
Provider Name (Legal Business Name): LEAH MARIE MARK MS, RD, CDN, CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2018
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 GREEN ST STE 2
HUNTINGTON NY
11743-3393
US

IV. Provider business mailing address

6 PLOVER LN
LLOYD HARBOR NY
11743-1037
US

V. Phone/Fax

Practice location:
  • Phone: 516-806-0045
  • Fax: 516-861-0061
Mailing address:
  • Phone: 516-810-8808
  • Fax: 516-300-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number008091
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number008091
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number008091
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number008091
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number008091
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008091
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: