Provider Demographics
NPI:1093918450
Name:SCOTT, GWEN MARIE (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:GWEN MARIE
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:287 MAIN ST
Mailing Address - Street 2:STE. 301
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7054
Mailing Address - Country:US
Mailing Address - Phone:207-795-7520
Mailing Address - Fax:207-795-7179
Practice Address - Street 1:287 MAIN ST
Practice Address - Street 2:STE. 301
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7054
Practice Address - Country:US
Practice Address - Phone:207-795-7520
Practice Address - Fax:207-795-7179
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI219133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESCMT0082Medicare ID - Type Unspecified