Provider Demographics
NPI:1467111609
Name:GERONIMO, ALI (MED, RD, LDN, ATC)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:GERONIMO
Suffix:
Gender:F
Credentials:MED, RD, LDN, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-1608
Mailing Address - Country:US
Mailing Address - Phone:617-229-5146
Mailing Address - Fax:
Practice Address - Street 1:152 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:HOLLISTON
Practice Address - State:MA
Practice Address - Zip Code:01746-1608
Practice Address - Country:US
Practice Address - Phone:617-229-5146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5388133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered