Provider Demographics
NPI:1992751309
Name:CONKLIN, DOLLY ANN (RD)
Entity type:Individual
Prefix:
First Name:DOLLY
Middle Name:ANN
Last Name:CONKLIN
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 1:3298 ROUTE 94
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-4106
Mailing Address - Country:US
Mailing Address - Phone:845-457-5555
Mailing Address - Fax:845-457-5556
Practice Address - Street 1:20 WALNUT ST
Practice Address - Street 2:SUITE B
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-2230
Practice Address - Country:US
Practice Address - Phone:845-457-5555
Practice Address - Fax:845-457-5556
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006118133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered