Provider Demographics
NPI:1073335279
Name:LEA, MARY LOUISE (RD CDN)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LOUISE
Last Name:LEA
Suffix:
Gender:F
Credentials:RD CDN
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:LOUISE
Other - Last Name:BENENATI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 VILLAGE DR W
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8127
Mailing Address - Country:US
Mailing Address - Phone:631-513-8146
Mailing Address - Fax:
Practice Address - Street 1:18 VILLAGE DR W
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-8127
Practice Address - Country:US
Practice Address - Phone:631-513-8146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY802160133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered