Healthcare Provider Details

I. General information

NPI: 1760453971
Provider Name (Legal Business Name): PATRICIA D ENDY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 05/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4965 S EAGLE VILLAGE RD
MANLIUS NY
13104-9459
US

IV. Provider business mailing address

4965 S EAGLE VILLAGE RD
MANLIUS NY
13104-9459
US

V. Phone/Fax

Practice location:
  • Phone: 315-395-6412
  • Fax:
Mailing address:
  • Phone: 315-395-6412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006294-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: