Provider Demographics
NPI:1124799309
Name:DONOVAN, MAURA A (RD, LDN, CPT)
Entity type:Individual
Prefix:
First Name:MAURA
Middle Name:A
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:RD, LDN, CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23B GARDNER ST
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-1727
Mailing Address - Country:US
Mailing Address - Phone:603-321-2152
Mailing Address - Fax:
Practice Address - Street 1:126 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-2536
Practice Address - Country:US
Practice Address - Phone:617-744-9233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5383133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered