Provider Demographics
NPI:1003033531
Name:DER AVEDISSIAN, MARY-JEANNE (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:MARY-JEANNE
Middle Name:
Last Name:DER AVEDISSIAN
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-1612
Mailing Address - Country:US
Mailing Address - Phone:818-240-4328
Mailing Address - Fax:
Practice Address - Street 1:626 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1612
Practice Address - Country:US
Practice Address - Phone:818-240-4328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA590756133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered