Provider Demographics
NPI:1053839605
Name:PINEAU, MARA
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:PINEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631
Mailing Address - Country:US
Mailing Address - Phone:855-446-5937
Mailing Address - Fax:740-441-3379
Practice Address - Street 1:100 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631
Practice Address - Country:US
Practice Address - Phone:855-446-5937
Practice Address - Fax:740-441-3379
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPD.10816133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered