Provider Demographics
NPI:1972112845
Name:FALISE, HEATHER MARIE (RD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:FALISE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 GUY YOUNG RD
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-9767
Mailing Address - Country:US
Mailing Address - Phone:315-813-3361
Mailing Address - Fax:
Practice Address - Street 1:5261 GUY YOUNG RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-9767
Practice Address - Country:US
Practice Address - Phone:315-813-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86101877133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty