Provider Demographics
NPI:1255839908
Name:WINTERS, MARISSA (RDN)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:WINTERS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 ROUTE 66 FL 3
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2605
Mailing Address - Country:US
Mailing Address - Phone:732-807-0463
Mailing Address - Fax:201-751-1680
Practice Address - Street 1:27 S COOKS BRIDGE RD STE 2-3
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2524
Practice Address - Country:US
Practice Address - Phone:732-994-7855
Practice Address - Fax:732-242-6688
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ806641133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPENDINGMedicaid