Provider Demographics
NPI:1114056330
Name:REYNOLDS, MARIE DIANE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:DIANE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3516 WILDWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-4348
Mailing Address - Country:US
Mailing Address - Phone:214-325-1956
Mailing Address - Fax:
Practice Address - Street 1:6200 W PARKER RD
Practice Address - Street 2:NUTRITION SERVICES
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7939
Practice Address - Country:US
Practice Address - Phone:972-981-8444
Practice Address - Fax:972-981-8173
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07294133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered