Basic Information
| Provider Information | |||||||||
| NPI: | 1578167235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGELHARDT | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | RDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 LINN ST | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490101524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894506276 | ||||||||
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| Practice Location | |||||||||
| Address1: | 555 LINN ST | ||||||||
| Address2: | |||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490101524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696864251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2020 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86098171 | MI | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.