Provider Demographics
NPI:1730648858
Name:WARDNER, ELISHA (RD)
Entity Type:Individual
Prefix:
First Name:ELISHA
Middle Name:
Last Name:WARDNER
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 1:25 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02048-1680
Mailing Address - Country:US
Mailing Address - Phone:603-440-3971
Mailing Address - Fax:
Practice Address - Street 1:100 MORSE ST STE 2
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-4679
Practice Address - Country:US
Practice Address - Phone:781-269-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4773133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered