Healthcare Provider Details

I. General information

NPI: 1750463147
Provider Name (Legal Business Name): WENDY F ELVERSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

12 CLAREMONT PARK APT 1
BOSTON MA
02118-3028
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6177
  • Fax: 617-730-0496
Mailing address:
  • Phone: 617-424-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number178
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: