Provider Demographics
NPI:1134114242
Name:CORNETTA, MARY DALE (LDN, RD)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:DALE
Last Name:CORNETTA
Suffix:
Gender:F
Credentials:LDN, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2092
Mailing Address - Country:US
Mailing Address - Phone:318-537-3058
Mailing Address - Fax:318-327-4941
Practice Address - Street 1:309 JACKSON ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7407
Practice Address - Country:US
Practice Address - Phone:318-327-4072
Practice Address - Fax:318-327-4941
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1735133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA133NN1002XMedicare ID - Type UnspecifiedNUTRITION EDUCATION
LA133VN1005XMedicare ID - Type UnspecifiedNUTRITIONIST
LA133VN1004XMedicare ID - Type UnspecifiedPEDIATRIC
LA133VN1005XMedicare ID - Type UnspecifiedRENAL
LA133V00000XMedicare ID - Type UnspecifiedRD