Provider Demographics
NPI:1427264605
Name:MARDIGAN, TARA (MS, MPH, RD)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:
Last Name:MARDIGAN
Suffix:
Gender:F
Credentials:MS, MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BROOKLINE AVE
Mailing Address - Street 2:APT 217
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-3406
Mailing Address - Country:US
Mailing Address - Phone:617-529-7784
Mailing Address - Fax:
Practice Address - Street 1:44 BINNEY ST
Practice Address - Street 2:SHIELDS WARREN 5TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6013
Practice Address - Country:US
Practice Address - Phone:617-632-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1791133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered