Provider Demographics
NPI:1043340110
Name:MARSELLE, DEANNE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:DEANNE
Middle Name:MARIE
Last Name:MARSELLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13400 LAKEFRONT DR
Mailing Address - Street 2:
Mailing Address - City:EARTH CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63045-1516
Mailing Address - Country:US
Mailing Address - Phone:314-291-2900
Mailing Address - Fax:
Practice Address - Street 1:13400 LAKEFRONT DR
Practice Address - Street 2:
Practice Address - City:EARTH CITY
Practice Address - State:MO
Practice Address - Zip Code:63045-1516
Practice Address - Country:US
Practice Address - Phone:314-291-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.004365133V00000X
MO2005037494133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1043340110OtherWELLCARE OF MISSOURI
IL164.004365OtherSTATE LICENSE
MO1043340110OtherESSENCE
MO1043340110OtherCOVENTRY HEALTHCARE
MO1043340110OtherAETNA
MO1043340110OtherCIGNA
MOP01123177OtherRAILROAD MEDICARE
721252OtherREGISTERED DIETITIAN
MO1043340110OtherWELLCARE OF MISSOURI