Provider Demographics
NPI:1053655407
Name:WALSH, MARYANN (RD)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:WALSH
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 1:438 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-1622
Mailing Address - Country:US
Mailing Address - Phone:401-742-0947
Mailing Address - Fax:
Practice Address - Street 1:438 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-1622
Practice Address - Country:US
Practice Address - Phone:401-742-0947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered