Healthcare Provider Details

I. General information

NPI: 1821328758
Provider Name (Legal Business Name): MARY ELIZABETH DEGNAN MS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2009
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 10TH ST
NIAGARA FALLS NY
14301-1813
US

IV. Provider business mailing address

176 B HIGHLAND DRIVE
WILLIAMSVILLE NY
14221-1235
US

V. Phone/Fax

Practice location:
  • Phone: 716-278-4360
  • Fax: 716-278-4266
Mailing address:
  • Phone: 716-957-2285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number007089
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: