Provider Demographics
NPI:1790901197
Name:JUDY, MARYBETH (MS, RDN, LD)
Entity Type:Individual
Prefix:MS
First Name:MARYBETH
Middle Name:
Last Name:JUDY
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 SCHOOL HOUSE RD STE 14
Mailing Address - Street 2:
Mailing Address - City:ORLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04472-3966
Mailing Address - Country:US
Mailing Address - Phone:207-752-2341
Mailing Address - Fax:855-752-0261
Practice Address - Street 1:21 SCHOOL HOUSE RD STE 14
Practice Address - Street 2:
Practice Address - City:ORLAND
Practice Address - State:ME
Practice Address - Zip Code:04472-3966
Practice Address - Country:US
Practice Address - Phone:207-752-2341
Practice Address - Fax:855-752-0261
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X
MED1408133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
1790901197OtherNPI
MED1408OtherLICENSE