Provider Demographics
NPI:1639146186
Name:CLANCY, CORINNE L (RD)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:L
Last Name:CLANCY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 OBERY ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2237
Mailing Address - Country:US
Mailing Address - Phone:508-210-5920
Mailing Address - Fax:
Practice Address - Street 1:46 OBERY ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2237
Practice Address - Country:US
Practice Address - Phone:508-210-5920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA334133V00000X
MA876364133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMT0277Medicare ID - Type Unspecified