Provider Demographics
NPI:1932523800
Name:DISANTO, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DISANTO
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 1:3 LONGUE VUE AVE
Mailing Address - Street 2:
Mailing Address - City:N PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-4226
Mailing Address - Country:US
Mailing Address - Phone:401-241-4119
Mailing Address - Fax:
Practice Address - Street 1:200 HIGH SERVICE AVE
Practice Address - Street 2:
Practice Address - City:NORTH PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-5113
Practice Address - Country:US
Practice Address - Phone:401-456-3193
Practice Address - Fax:401-456-6742
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
RILDN00035OtherLICENSE