Basic Information
| Provider Information | |||||||||
| NPI: | 1992751309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | DOLLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3298 ROUTE 94 | ||||||||
| Address2: | |||||||||
| City: | CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109184106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454575555 | ||||||||
| FaxNumber: | 8454575556 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 WALNUT ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125492230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454575555 | ||||||||
| FaxNumber: | 8454575556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 006118 | NY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.