Provider Demographics
NPI:1992776959
Name:FARLEY-CORNELL, COLLEEN FRANCES (RD, CDN, CDE)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:FRANCES
Last Name:FARLEY-CORNELL
Suffix:
Gender:F
Credentials:RD, CDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:964 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-6038
Mailing Address - Country:US
Mailing Address - Phone:516-996-2204
Mailing Address - Fax:
Practice Address - Street 1:964 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-6038
Practice Address - Country:US
Practice Address - Phone:516-996-2204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002701-1133N00000X, 133V00000X
NY002701133NN1002X
NY727425133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY9410E1Medicare ID - Type UnspecifiedC MNT MNT