Healthcare Provider Details

I. General information

NPI: 1891708046
Provider Name (Legal Business Name): JUDY R KIRK MS RD CON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 LIBERTY ST STE 1116
PENN YAN NY
14527
US

IV. Provider business mailing address

417 LIBERTY STREET STE 1116
PENN YAN NY
14527-1124
US

V. Phone/Fax

Practice location:
  • Phone: 315-536-5515
  • Fax:
Mailing address:
  • Phone: 315-536-5515
  • Fax: 315-536-5514

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: