Provider Demographics
NPI:1386884542
Name:MOORE-BOYLE, MELISSA J (MS, RD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:MOORE-BOYLE
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-2019
Mailing Address - Country:US
Mailing Address - Phone:781-355-2119
Mailing Address - Fax:
Practice Address - Street 1:150 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-4817
Practice Address - Country:US
Practice Address - Phone:857-364-5963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-02
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2803133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ08608Medicare UPIN