Provider Demographics
NPI:1770914020
Name:FITZGERALD, RUTH
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 CHERRY ST
Mailing Address - Street 2:APT 3
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-3935
Mailing Address - Country:US
Mailing Address - Phone:603-502-0649
Mailing Address - Fax:781-278-6477
Practice Address - Street 1:85 CHERRY ST
Practice Address - Street 2:APT 3
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-3935
Practice Address - Country:US
Practice Address - Phone:603-502-0649
Practice Address - Fax:781-278-6477
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3087133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered