Provider Demographics
NPI:1962810309
Name:IPSEN, ANNA (BS)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:IPSEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 HOLLANDALE LN APT B
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-5232
Mailing Address - Country:US
Mailing Address - Phone:518-487-1524
Mailing Address - Fax:
Practice Address - Street 1:38 HOLLANDALE LN APT B
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-5232
Practice Address - Country:US
Practice Address - Phone:518-487-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY526008517133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist