Healthcare Provider Details

I. General information

NPI: 1336342633
Provider Name (Legal Business Name): POONHAR LOUISA POON MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 KNEELAND ST STE 5
BOSTON MA
02111-1523
US

IV. Provider business mailing address

29 HARVARD AVE UNIT 24
MEDFORD MA
02155-3573
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-9941
  • Fax:
Mailing address:
  • Phone: 781-475-8687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number2087
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: