Provider Demographics
NPI:1275154437
Name:PARK, MARINA (MS, RD)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:PARK
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 BREMO RD STE 605
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1926
Mailing Address - Country:US
Mailing Address - Phone:804-281-8303
Mailing Address - Fax:
Practice Address - Street 1:5855 BREMO RD STE 605
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1926
Practice Address - Country:US
Practice Address - Phone:804-281-8303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1036132133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered