Provider Demographics
NPI:1033518618
Name:LEVY, PRUDENCE (RD)
Entity Type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
Last Name:LEVY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 WEST TISBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:EDGATOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02539
Mailing Address - Country:US
Mailing Address - Phone:508-627-3235
Mailing Address - Fax:508-627-7270
Practice Address - Street 1:140 COOKE STREET
Practice Address - Street 2:
Practice Address - City:EDGARTOWN
Practice Address - State:MA
Practice Address - Zip Code:02539
Practice Address - Country:US
Practice Address - Phone:508-627-3235
Practice Address - Fax:508-627-7270
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered