Provider Demographics
NPI:1871767699
Name:FERNALD, ALISON R (RD, LD, CDE)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:R
Last Name:FERNALD
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2764
Mailing Address - Country:US
Mailing Address - Phone:207-406-7290
Mailing Address - Fax:207-406-7291
Practice Address - Street 1:81 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 2200
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2764
Practice Address - Country:US
Practice Address - Phone:207-406-7290
Practice Address - Fax:207-406-7291
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MED1449133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
U400103184Medicare PIN