Provider Demographics
NPI:1922041300
Name:DRISCOLL, COURTNEY ROSE (RD LDN)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:ROSE
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 TERN ROAD
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:05664
Mailing Address - Country:US
Mailing Address - Phone:508-364-3549
Mailing Address - Fax:508-457-3977
Practice Address - Street 1:26 WAMPUM DRIVE
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631
Practice Address - Country:US
Practice Address - Phone:508-896-9080
Practice Address - Fax:508-896-3399
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2422133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2422OtherSTATE LICENSE #
MA2422OtherSTATE LICENSE #