Provider Demographics
NPI:1588392187
Name:CHANZIS, MOLLY CLEARY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:CLEARY
Last Name:CHANZIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MONROE ST STE E512
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6360
Mailing Address - Country:US
Mailing Address - Phone:917-647-1665
Mailing Address - Fax:201-473-5812
Practice Address - Street 1:99 MADISON AVE FL 505
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-7419
Practice Address - Country:US
Practice Address - Phone:917-647-1665
Practice Address - Fax:201-473-5812
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008663133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered