Provider Demographics
NPI:1255846630
Name:ANDERSON-CARDWELL, MARYSA CHIEKO (MS, RDN, LD)
Entity Type:Individual
Prefix:
First Name:MARYSA
Middle Name:CHIEKO
Last Name:ANDERSON-CARDWELL
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 S FOOTHILL DR STE 180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-5403
Mailing Address - Country:US
Mailing Address - Phone:385-722-4393
Mailing Address - Fax:
Practice Address - Street 1:2319 S FOOTHILL DR STE 180
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109-5403
Practice Address - Country:US
Practice Address - Phone:385-722-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10036060-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered