Provider Demographics
NPI:1265035968
Name:MADEIRA, MARISSA (MS, RDN)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MADEIRA
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:FLOWER MARISSA
Other - Middle Name:
Other - Last Name:MADEIRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:110 E HINES PL APT 4A3
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-7446
Mailing Address - Country:US
Mailing Address - Phone:808-206-3983
Mailing Address - Fax:
Practice Address - Street 1:110 E HINES PL APT 4A3
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-7446
Practice Address - Country:US
Practice Address - Phone:808-206-3983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered