Provider Demographics
NPI:1881815751
Name:YOUNG, AUDREY M (RD, LDN, CDE)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:M
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MYSTIC HEALTHCARE
Mailing Address - Street 2:137 MAIN STREET
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01255
Mailing Address - Country:US
Mailing Address - Phone:781-395-4761
Mailing Address - Fax:781-395-5081
Practice Address - Street 1:2 FIRST AVENUE CENTENNIAL CROSSING
Practice Address - Street 2:SUITE 112
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960
Practice Address - Country:US
Practice Address - Phone:617-240-6383
Practice Address - Fax:978-745-7982
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA901133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA00376201OtherMEDICARE PTAN