Provider Demographics
NPI:1235249566
Name:MACDONOUGH, MARYANN M (RD, LDN, CDE)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:M
Last Name:MACDONOUGH
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MERIAM ST
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-3633
Mailing Address - Country:US
Mailing Address - Phone:978-671-9118
Mailing Address - Fax:
Practice Address - Street 1:130 MARSHALL RD
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-5130
Practice Address - Country:US
Practice Address - Phone:978-671-9118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered