Provider Demographics
NPI:1053480749
Name:GARCIA, MARISSA P (MSH, RD)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:P
Last Name:GARCIA
Suffix:
Gender:F
Credentials:MSH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CORPORATE SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1941
Mailing Address - Country:US
Mailing Address - Phone:904-899-4500
Mailing Address - Fax:904-899-4534
Practice Address - Street 1:1900 CORPORATE SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1941
Practice Address - Country:US
Practice Address - Phone:904-899-4500
Practice Address - Fax:904-899-4534
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001051133V00000X
FLND0000057133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered