Healthcare Provider Details

I. General information

NPI: 1669082525
Provider Name (Legal Business Name): JENELLE INDELICATO RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 09/14/2021
Certification Date: 09/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MALL RD
BURLINGTON MA
01805-2713
US

IV. Provider business mailing address

50 MALL RD STE G03
BURLINGTON MA
01803-4529
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4005
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86056317
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number86056317
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number4005
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: