Healthcare Provider Details

I. General information

NPI: 1275315400
Provider Name (Legal Business Name): HEALTHFUL NUTRITION SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 11/18/2023
Certification Date: 11/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CRYSTAL HILL DR
POMONA NY
10970-2601
US

IV. Provider business mailing address

PO BOX 128
GARNERVILLE NY
10923-0128
US

V. Phone/Fax

Practice location:
  • Phone: 845-520-8336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: MARIE THEAGENE
Title or Position: OWNER
Credential: MS RD CSR CDN CDCES
Phone: 845-270-5775