Provider Demographics
NPI:1033403209
Name:DURST, ELLEN F (MS,RD,LD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:F
Last Name:DURST
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 GERALD ST
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3125
Mailing Address - Country:US
Mailing Address - Phone:662-335-4105
Mailing Address - Fax:662-378-2879
Practice Address - Street 1:1997 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7268
Practice Address - Country:US
Practice Address - Phone:662-335-4105
Practice Address - Fax:662-378-2879
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered