Healthcare Provider Details

I. General information

NPI: 1639649957
Provider Name (Legal Business Name): MARY J PLESAC RD LD MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY J COVEL

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 LAUREL CREST DRIVE
BROOKLINE NH
03033
US

IV. Provider business mailing address

26 LAUREL CREST DRIVE
BROOKLINE NH
03033
US

V. Phone/Fax

Practice location:
  • Phone: 603-801-1564
  • Fax:
Mailing address:
  • Phone: 603-801-1564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number690880
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: