Provider Demographics
NPI:1306879556
Name:TUDOR-CHAMPAGNE, JAIMI-LYN
Entity type:Individual
Prefix:
First Name:JAIMI-LYN
Middle Name:
Last Name:TUDOR-CHAMPAGNE
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 1:17 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:LANESBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01237-9753
Mailing Address - Country:US
Mailing Address - Phone:518-857-8286
Mailing Address - Fax:
Practice Address - Street 1:725 NORTH ST
Practice Address - Street 2:
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-4109
Practice Address - Country:US
Practice Address - Phone:413-447-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY934434133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered