Healthcare Provider Details

I. General information

NPI: 1619924040
Provider Name (Legal Business Name): DEBORAH L FENNELL R.D., CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 BURWELL ST
LITTLE FALLS NY
13365-1725
US

IV. Provider business mailing address

200 FAIRWAY DR
NEW HARTFORD NY
13413-1010
US

V. Phone/Fax

Practice location:
  • Phone: 315-823-5381
  • Fax:
Mailing address:
  • Phone: 315-738-0526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006088-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: