Basic Information
| Provider Information | |||||||||
| NPI: | 1407131519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAXWELL | ||||||||
| FirstName: | MARJORIE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | R.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23340 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631563340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148513307 | ||||||||
| FaxNumber: | 3146477967 | ||||||||
| Practice Location | |||||||||
| Address1: | 1027 BELLEVUE AVE | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631171851 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148513307 | ||||||||
| FaxNumber: | 3146477967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2011 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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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 | 2001025981 | MO | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.