Healthcare Provider Details

I. General information

NPI: 1689194201
Provider Name (Legal Business Name): NUTRITION 365
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 NORTH RD
DEERFIELD NH
03037-1105
US

IV. Provider business mailing address

236 NORTH RD
DEERFIELD NH
03037-1105
US

V. Phone/Fax

Practice location:
  • Phone: 781-858-2500
  • Fax:
Mailing address:
  • Phone: 781-858-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0631
License Number StateNH

VIII. Authorized Official

Name: MRS. JULIE CATHERINE COSTANZO
Title or Position: OWNER
Credential: RD, LD
Phone: 781-858-2500