Provider Demographics
NPI:1215175633
Name:YOUNG, ILISA R (PHD, RD, CDN)
Entity type:Individual
Prefix:
First Name:ILISA
Middle Name:R
Last Name:YOUNG
Suffix:
Gender:F
Credentials:PHD, RD, CDN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, RD, CDN
Mailing Address - Street 1:401 E 88TH ST
Mailing Address - Street 2:SUITE 10E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-6605
Mailing Address - Country:US
Mailing Address - Phone:212-860-4776
Mailing Address - Fax:212-860-4776
Practice Address - Street 1:401 E 88TH ST
Practice Address - Street 2:SUITE 10E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-6605
Practice Address - Country:US
Practice Address - Phone:212-860-4776
Practice Address - Fax:212-860-4776
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002317133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist