Provider Demographics
NPI:1942020961
Name:STEVENS, KARISSA SUZANNE (RDN, CDN)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:SUZANNE
Last Name:STEVENS
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 PROSPECT PL APT 7E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-4275
Mailing Address - Country:US
Mailing Address - Phone:203-479-2859
Mailing Address - Fax:
Practice Address - Street 1:300 CADMAN PLZ W
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3229
Practice Address - Country:US
Practice Address - Phone:212-828-7473
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010936133V00000X
CT86169602133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered