Healthcare Provider Details

I. General information

NPI: 1801317706
Provider Name (Legal Business Name): KIM HALI WOLF MS, RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2017
Last Update Date: 06/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 E MAIN ST STE 105
SMITHTOWN NY
11787-2912
US

IV. Provider business mailing address

20 SWALLOW LN
HAUPPAUGE NY
11788-2220
US

V. Phone/Fax

Practice location:
  • Phone: 631-509-0390
  • Fax:
Mailing address:
  • Phone: 631-724-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number008749
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: