Provider Demographics
NPI:1447466891
Name:ELLIS-WOOD, KRISTIN L (RD, CDN)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:L
Last Name:ELLIS-WOOD
Suffix:
Gender:F
Credentials: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:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:WHIPPLEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12995-0035
Mailing Address - Country:US
Mailing Address - Phone:518-483-3000
Mailing Address - Fax:
Practice Address - Street 1:133 PARK ST
Practice Address - Street 2:ALICE HYDE MEDICAL CENTER
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1220
Practice Address - Country:US
Practice Address - Phone:518-483-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005293133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD3292Medicare ID - Type Unspecified