Provider Demographics
NPI:1609931609
Name:LYDEN, JUDITH L (RD CDE)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:L
Last Name:LYDEN
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:110 W SQUANTUM ST
Mailing Address - Street 2:MANET COMMUNITY HEALTH CENTER INC
Mailing Address - City:NO QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2122
Mailing Address - Country:US
Mailing Address - Phone:617-376-3000
Mailing Address - Fax:617-774-1906
Practice Address - Street 1:180 GEORGE WASHINGTON BLVD
Practice Address - Street 2:MANET COMMUNITY HEALTH CENTER
Practice Address - City:HULL
Practice Address - State:MA
Practice Address - Zip Code:02045-3069
Practice Address - Country:US
Practice Address - Phone:781-925-4550
Practice Address - Fax:781-925-5052
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA1438133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0352Medicare ID - Type Unspecified