Provider Demographics
NPI:1548781909
Name:WITTNEBEN, ELLEN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WITTNEBEN
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:ELLE
Other - Middle Name:
Other - Last Name:WITTNEBEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:125 PARKER HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02120-2847
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 PARKER HILL AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02120-2847
Practice Address - Country:US
Practice Address - Phone:617-754-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4282133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered