Basic Information
| Provider Information | |||||||||
| NPI: | 1467525097 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUGLIESE | ||||||||
| FirstName: | MARCY | ||||||||
| MiddleName: | MCELVEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCELVEEN | ||||||||
| OtherFirstName: | MARCY | ||||||||
| OtherMiddleName: | LORIE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301651625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062955331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 172 THREE RIVERS DR NE | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301614999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062346905 | ||||||||
| FaxNumber: | 7062917792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD002762 | GA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 246904735B | 05 | GA | MEDICAID | 246904735C | 05 | GA | MEDICAID | 246904735A | 05 | GA | MEDICAID |