Provider Demographics
NPI:1316910235
Name:O'DONNELL, MARLENE (RD)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:
Last Name:O'DONNELL
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 1:111 GROSSMAN DR
Mailing Address - Street 2:
Mailing Address - City:BRAINTREE
Mailing Address - State:MA
Mailing Address - Zip Code:02184-4997
Mailing Address - Country:US
Mailing Address - Phone:617-629-6444
Mailing Address - Fax:617-629-6070
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:617-629-6444
Practice Address - Fax:617-629-6070
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1403133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALD0111OtherBLUE CROSS
MA680078OtherTUFTS HEALTH PLAN
MA0015208OtherNEIGHBORHOOD HEALTH PLAN
MAPQ116OtherHARVARD PILGRIM
MAPQ116OtherHARVARD PILGRIM