Basic Information
| Provider Information | |||||||||
| NPI: | 1255839908 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WINTERS | ||||||||
| FirstName: | MARISSA | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 ROUTE 66 FL 3 | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077532605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328070463 | ||||||||
| FaxNumber: | 2017511680 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 S COOKS BRIDGE RD STE 2-3 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 085272524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329947855 | ||||||||
| FaxNumber: | 7322426688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2018 | ||||||||
| LastUpdateDate: | 01/29/2018 | ||||||||
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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 | 806641 | NJ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | NJ | MEDICAID |