Healthcare Provider Details

I. General information

NPI: 1609770783
Provider Name (Legal Business Name): CASSADEY ELYSE PORTER MDN, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 FORMAN AVE # 4014
SYRACUSE NY
13210-1568
US

IV. Provider business mailing address

311 FORMAN AVE # 4014
SYRACUSE NY
13210-1568
US

V. Phone/Fax

Practice location:
  • Phone: 206-819-5397
  • Fax:
Mailing address:
  • Phone: 206-819-5397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: