Provider Demographics
NPI:1790076883
Name:DAVIS, MARA (MS, RD, CD-N, LDN)
Entity Type:Individual
Prefix:MISS
First Name:MARA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MS, RD, CD-N, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 BRETTON RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4111
Mailing Address - Country:US
Mailing Address - Phone:860-796-1930
Mailing Address - Fax:860-545-3765
Practice Address - Street 1:5901 KINGSTOWNE VILLAGE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5883
Practice Address - Country:US
Practice Address - Phone:860-796-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-25
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001415133V00000X
NC919705133V00000X
VA919705133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered