Healthcare Provider Details

I. General information

NPI: 1558038232
Provider Name (Legal Business Name): UTICA NUTRITION SERVICES CERTIFIED DIETITIAN NUTRITIONIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 GENESEE ST STE 213
UTICA NY
13501-6222
US

IV. Provider business mailing address

PO BOX 377
NEW HARTFORD NY
13413-0377
US

V. Phone/Fax

Practice location:
  • Phone: 315-922-3192
  • Fax:
Mailing address:
  • Phone: 315-922-3192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: CLEANNE LYNN JOHNSON
Title or Position: CERTIFIED DIETITIAN NUTRITIONIST
Credential: CDN
Phone: 315-922-3192