Provider Demographics
NPI:1992981419
Name:LAVANWAY, MARY ELLEN (RD, LD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:LAVANWAY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2A CONSTITUTION AVE
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-1330
Mailing Address - Country:US
Mailing Address - Phone:207-862-2303
Mailing Address - Fax:207-862-2303
Practice Address - Street 1:2A CONSTITUTION AVE
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-1330
Practice Address - Country:US
Practice Address - Phone:207-862-2303
Practice Address - Fax:207-862-2303
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI877133V00000X
NH3133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered