Provider Demographics
NPI:1487690640
Name:SIMON, ILYSE A (RD, CDN)
Entity type:Individual
Prefix:MS
First Name:ILYSE
Middle Name:A
Last Name:SIMON
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 1:231 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-8003
Mailing Address - Country:US
Mailing Address - Phone:845-331-6381
Mailing Address - Fax:
Practice Address - Street 1:231 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5030
Practice Address - Country:US
Practice Address - Phone:845-331-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006097133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY710000064Medicare ID - Type Unspecified