Provider Demographics
NPI:1619623980
Name:OTIENO-WASONGA, NORAH ALILA (RD)
Entity Type:Individual
Prefix:
First Name:NORAH
Middle Name:ALILA
Last Name:OTIENO-WASONGA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:NORAH
Other - Middle Name:ALILA
Other - Last Name:WASONGA-GERMAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:163 GORE ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02141-1119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:163 GORE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1119
Practice Address - Country:US
Practice Address - Phone:781-605-4532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5534-NU-NU133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered