Provider Demographics
NPI:1174077226
Name:SERGENT, CHRISTINE MARY (RD, CDN)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARY
Last Name:SERGENT
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 1314
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-1314
Mailing Address - Country:US
Mailing Address - Phone:845-206-1799
Mailing Address - Fax:
Practice Address - Street 1:243 PUGSLEY HILL RD
Practice Address - Street 2:
Practice Address - City:AMENIA
Practice Address - State:NY
Practice Address - Zip Code:12501-5008
Practice Address - Country:US
Practice Address - Phone:845-206-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY726035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY726035OtherACADEMY OF NUTRITION AND DIETETICS MEMBER
NY001537-1OtherNYS DEPARTMENTOF EDUCATION LICENSE