Provider Demographics
NPI:1003357179
Name:LYDON, KARA (RD, LDN, RYT)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:
Last Name:LYDON
Suffix:
Gender:F
Credentials:RD, LDN, RYT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 ARBORWAY
Mailing Address - Street 2:UNIT 5
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3522
Mailing Address - Country:US
Mailing Address - Phone:716-200-3236
Mailing Address - Fax:
Practice Address - Street 1:30 NEWBURY ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3236
Practice Address - Country:US
Practice Address - Phone:716-200-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3090133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered