Provider Demographics
NPI:1871625715
Name:MAILLOUX, JOANNE C (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:C
Last Name:MAILLOUX
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1336
Mailing Address - Country:US
Mailing Address - Phone:978-630-6234
Mailing Address - Fax:978-630-6820
Practice Address - Street 1:242 GREEN ST
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1336
Practice Address - Country:US
Practice Address - Phone:978-630-6234
Practice Address - Fax:978-630-6820
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1966133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered