Healthcare Provider Details

I. General information

NPI: 1437516424
Provider Name (Legal Business Name): ALISSA MOYNAGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 10/23/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 WINTHROP SHORE DR APT 5
WINTHROP MA
02152-1153
US

IV. Provider business mailing address

249 WINTHROP SHORE DR APT 5
WINTHROP MA
02152-1153
US

V. Phone/Fax

Practice location:
  • Phone: 508-954-0751
  • Fax:
Mailing address:
  • Phone: 508-954-0751
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3199
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: