Healthcare Provider Details

I. General information

NPI: 1295951143
Provider Name (Legal Business Name): MARA ROSE SANSEVERO REGISTERED DIETITIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 08/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S HUNTINGTON AVE BRIGHAM & WOMEN'S ADVANCED PRIMARY CARE ASSOCIATES, SH
JAMAICA PLAIN MA
02130-4807
US

IV. Provider business mailing address

301 S HUNTINGTON AVE BRIGHAM & WOMEN'S ADVANCED PRIMARY CARE ASSOCIATES, SH
JAMAICA PLAIN MA
02130-4807
US

V. Phone/Fax

Practice location:
  • Phone: 857-307-3364
  • Fax:
Mailing address:
  • Phone: 857-307-3364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2140
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: