Healthcare Provider Details

I. General information

NPI: 1083836811
Provider Name (Legal Business Name): LEONIE GENUS COWAN MS RDCN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 ROUTE 300 SUITE 102
NEWBURGH NY
12550-1738
US

IV. Provider business mailing address

1607 ROUTE 300 SUITE 102
NEWBURGH NY
12550-1738
US

V. Phone/Fax

Practice location:
  • Phone: 845-564-9853
  • Fax: 845-564-6974
Mailing address:
  • Phone: 845-564-9853
  • Fax: 845-564-6974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number001475-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: