Healthcare Provider Details

I. General information

NPI: 1639146186
Provider Name (Legal Business Name): CORINNE L CLANCY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2006
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 OBERY ST
PLYMOUTH MA
02360-2237
US

IV. Provider business mailing address

46 OBERY ST
PLYMOUTH MA
02360-2237
US

V. Phone/Fax

Practice location:
  • Phone: 508-210-5920
  • Fax:
Mailing address:
  • Phone: 508-210-5920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number334
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: