Provider Demographics
NPI:1316515208
Name:DIETITIANS OF NORTHERN NEW YORK, PLLC.
Entity type:Organization
Organization Name:DIETITIANS OF NORTHERN NEW YORK, PLLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ETOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, CDCES
Authorized Official - Phone:315-221-4881
Mailing Address - Street 1:415 SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-3920
Mailing Address - Country:US
Mailing Address - Phone:315-221-4881
Mailing Address - Fax:315-777-4111
Practice Address - Street 1:415 SHERMAN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-3920
Practice Address - Country:US
Practice Address - Phone:315-221-4881
Practice Address - Fax:315-777-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty