Provider Demographics
NPI:1679757900
Name:FARRELLY, MARY JO HANNA (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY JO
Middle Name:HANNA
Last Name:FARRELLY
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:267 GRANT ST
Mailing Address - Street 2:DIABETES EDUCATION CENTER
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-5000
Mailing Address - Country:US
Mailing Address - Phone:203-336-7305
Mailing Address - Fax:203-384-4274
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:DIABETES EDUCATION CENTER
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-5000
Practice Address - Country:US
Practice Address - Phone:203-336-7305
Practice Address - Fax:203-384-4274
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000587Medicare PIN