Healthcare Provider Details

I. General information

NPI: 1700209038
Provider Name (Legal Business Name): MARY SHEA ROSEN RD,MS,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 GUILFORD ST
BRATTLEBORO VT
05301-6401
US

IV. Provider business mailing address

449 GUILFORD ST
BRATTLEBORO VT
05301-6401
US

V. Phone/Fax

Practice location:
  • Phone: 802-257-9566
  • Fax: 802-257-9566
Mailing address:
  • Phone: 802-257-9566
  • Fax: 802-257-9566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberR422803
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR422803
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberR422803
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: