Provider Demographics
NPI:1124297775
Name:HIXSON, MARY LYNNE (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LYNNE
Last Name:HIXSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3238
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241
Mailing Address - Country:US
Mailing Address - Phone:866-689-8862
Mailing Address - Fax:207-347-7401
Practice Address - Street 1:ONE HOPPIN ST.
Practice Address - Street 2:CORO CENTER, 3RD FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903
Practice Address - Country:US
Practice Address - Phone:401-793-8790
Practice Address - Fax:401-793-8709
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-28
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00107133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered