Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 03288 | MA |
NPI | 1336451244 |
---|---|
Provider Name | Dr. Misty Beck Kosciusko |
First Address | Portsmouth, RI 02871-2348 |
Second Address | Portsmouth, RI 02871-2348 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/07/2010 |
Last Update Date | 02/10/2012 |