Healthcare Provider Details

I. General information

NPI: 1942318571
Provider Name (Legal Business Name): MARY ANN GRAHAM MSRD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 PLANTATION STREET
WORCESTER MA
01605
US

IV. Provider business mailing address

630 PLANTATION STREET
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 508-852-6175
  • Fax: 508-595-2941
Mailing address:
  • Phone: 508-852-6175
  • Fax: 508-595-2941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number216
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number216
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: