Provider Demographics
NPI:1902862584
Name:VAN WART, MONA ELIIZABETH (RD LD)
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:ELIIZABETH
Last Name:VAN WART
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 1:874 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDDYBEMPS
Mailing Address - State:ME
Mailing Address - Zip Code:04657-4119
Mailing Address - Country:US
Mailing Address - Phone:207-454-8248
Mailing Address - Fax:
Practice Address - Street 1:24 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:CALAIS
Practice Address - State:ME
Practice Address - Zip Code:04619-1329
Practice Address - Country:US
Practice Address - Phone:207-454-3906
Practice Address - Fax:207-454-3616
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME687830133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMT0334Medicare ID - Type Unspecified
MEMT033401Medicare PIN