Healthcare Provider Details

I. General information

NPI: 1952639635
Provider Name (Legal Business Name): RENEE A SIMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 11/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 GILBERT ST
SOUTH SALEM NY
10590-1341
US

IV. Provider business mailing address

15 GILBERT ST
SOUTH SALEM NY
10590-1341
US

V. Phone/Fax

Practice location:
  • Phone: 914-763-9107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number005272
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: