Provider Demographics
NPI:1508068966
Name:BERTHIAUME, AYN L (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:AYN
Middle Name:L
Last Name:BERTHIAUME
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 DAY ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-4316
Mailing Address - Country:US
Mailing Address - Phone:978-345-8501
Mailing Address - Fax:978-342-0855
Practice Address - Street 1:66 DAY ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-4316
Practice Address - Country:US
Practice Address - Phone:978-345-8501
Practice Address - Fax:978-342-0855
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMT0812Medicare ID - Type UnspecifiedMEDICARE NUMBER