Provider Demographics
NPI:1245239151
Name:HENDERSON, MARYANNE ELIZABETH (RD, LD/N)
Entity Type:Individual
Prefix:MRS
First Name:MARYANNE
Middle Name:ELIZABETH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-6511
Mailing Address - Country:US
Mailing Address - Phone:954-923-6500
Mailing Address - Fax:
Practice Address - Street 1:1520 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6511
Practice Address - Country:US
Practice Address - Phone:954-401-2946
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3567133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL920412785204Medicare ID - Type UnspecifiedPARTICIPATING PROVIDER