Healthcare Provider Details

I. General information

NPI: 1699729764
Provider Name (Legal Business Name): JACQUELINE DEVNO GRENNELL RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64R GUNNERS EXCHANGE RD
PLYMOUTH MA
02360-3124
US

IV. Provider business mailing address

64R GUNNERS EXCHANGE RD
PLYMOUTH MA
02360-3124
US

V. Phone/Fax

Practice location:
  • Phone: 508-746-9030
  • Fax: 508-746-9030
Mailing address:
  • Phone: 508-746-9030
  • Fax: 508-746-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number395
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: