Provider Demographics
NPI:1275908998
Name:BOGARDUS, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:BOGARDUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 HERRICK ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-1790
Mailing Address - Country:US
Mailing Address - Phone:978-922-3000
Mailing Address - Fax:
Practice Address - Street 1:85 HERRICK ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-1790
Practice Address - Country:US
Practice Address - Phone:978-922-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3420133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3420OtherCOMMONWEALTH OF MASSACHUSETTS DIVISION OF LICENSURE BOARD OF DIETITIANS