Basic Information
| Provider Information | |||||||||
| NPI: | 1326165580 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDENBURG | ||||||||
| FirstName: | MARCIE | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1536 | ||||||||
| Address2: | |||||||||
| City: | LANESBORO | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012371536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134455949 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 725 NORTH ST | ||||||||
| Address2: | |||||||||
| City: | PITTSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012014109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134472000 | ||||||||
| FaxNumber: | 4134472605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 06/29/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 2342 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.