Provider Demographics
NPI:1679176630
Name:GOLLAN, MARY ELIZABETH (MS, RDN, CD-N, CLC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:GOLLAN
Suffix:
Gender:F
Credentials:MS, RDN, CD-N, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 WESTSIDE BLVD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-2526
Mailing Address - Country:US
Mailing Address - Phone:860-609-7327
Mailing Address - Fax:
Practice Address - Street 1:63 WESTSIDE BLVD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06013-2526
Practice Address - Country:US
Practice Address - Phone:860-609-7327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered