Provider Demographics
NPI:1013559483
Name:SMOLLER, MARIELLE ELIZABETH (MS, RD)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:ELIZABETH
Last Name:SMOLLER
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:MARIELLE
Other - Middle Name:ELIZABETH
Other - Last Name:MANGANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:4 CAREY ST
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-1047
Mailing Address - Country:US
Mailing Address - Phone:267-229-6506
Mailing Address - Fax:
Practice Address - Street 1:2002 SPROUL RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3510
Practice Address - Country:US
Practice Address - Phone:267-229-6506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86008269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty