Healthcare Provider Details

I. General information

NPI: 1891392312
Provider Name (Legal Business Name): DONNA LYNN WALSH MS,RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 STAGECOACH RD
LIBERTY ME
04949-3133
US

IV. Provider business mailing address

10 STAGECOACH RD
LIBERTY ME
04949-3133
US

V. Phone/Fax

Practice location:
  • Phone: 207-649-7422
  • Fax:
Mailing address:
  • Phone: 207-649-7422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI630
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License NumberDI630
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: