Provider Demographics
NPI:1558575183
Name:CORMIER, MICHELINE DORIS (RD LDN CNSD)
Entity Type:Individual
Prefix:MS
First Name:MICHELINE
Middle Name:DORIS
Last Name:CORMIER
Suffix:
Gender:F
Credentials:RD LDN CNSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 HARRIS RD # A
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4210
Mailing Address - Country:US
Mailing Address - Phone:781-393-8582
Mailing Address - Fax:617-983-7138
Practice Address - Street 1:41 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-1446
Practice Address - Country:US
Practice Address - Phone:617-983-7516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2150133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMT0621Medicare ID - Type Unspecified