Provider Demographics
NPI:1730227505
Name:KOENIG, VICKI C (MS, RD, CDN)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:C
Last Name:KOENIG
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 MAIN ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW PALTZ
Mailing Address - State:NY
Mailing Address - Zip Code:12561-1313
Mailing Address - Country:US
Mailing Address - Phone:845-255-2398
Mailing Address - Fax:
Practice Address - Street 1:231 MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW PALTZ
Practice Address - State:NY
Practice Address - Zip Code:12561-1313
Practice Address - Country:US
Practice Address - Phone:845-255-2398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002114-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY960486OtherMVP HEALTH PLAN
NY9025EMedicare ID - Type UnspecifiedRD PROVIDER