Healthcare Provider Details

I. General information

NPI: 1124140215
Provider Name (Legal Business Name): PAT VASCONCELLOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 FALMOUTH RD STE F
MASHPEE MA
02649-2611
US

IV. Provider business mailing address

7 WALKERWOODS DR
HARWICH MA
02645-2060
US

V. Phone/Fax

Practice location:
  • Phone: 508-246-1724
  • Fax:
Mailing address:
  • Phone: 508-246-1724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1741
License Number StateMA

VIII. Authorized Official

Name: PAT ANNA VASCONCELLOS
Title or Position: REGISTERED DIETITIAN, DIABETES EDUC
Credential: RD, CDE
Phone: 508-246-1724