Provider Demographics
NPI:1558071639
Name:DISSEN, ANYA (RDN, LD)
Entity Type:Individual
Prefix:
First Name:ANYA
Middle Name:
Last Name:DISSEN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 HARVARD ST APT 607
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3536
Mailing Address - Country:US
Mailing Address - Phone:410-310-7343
Mailing Address - Fax:
Practice Address - Street 1:41 DONALD B DEAN DR STE A
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3252
Practice Address - Country:US
Practice Address - Phone:207-661-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1621133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered