Healthcare Provider Details

I. General information

NPI: 1376172155
Provider Name (Legal Business Name): LINDSAY MARR RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

81 OGDEN RD
STAMFORD CT
06905-3210
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-5010
  • Fax:
Mailing address:
  • Phone: 203-921-7931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number001736
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: