Provider Demographics
NPI:1548080765
Name:SIDNAM, NANCY (RD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:SIDNAM
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 1:27 CYGNET DR
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3326
Mailing Address - Country:US
Mailing Address - Phone:631-806-4378
Mailing Address - Fax:
Practice Address - Street 1:27 CYGNET DR
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3326
Practice Address - Country:US
Practice Address - Phone:631-806-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered