Provider Demographics
NPI:1376180356
Name:KISSKO, MARCIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:KISSKO
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:MARCELLA
Other - Middle Name:
Other - Last Name:KISSKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, LD
Mailing Address - Street 1:2520 LONGVIEW ST STE 211
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-4201
Mailing Address - Country:US
Mailing Address - Phone:512-522-7793
Mailing Address - Fax:818-484-2316
Practice Address - Street 1:2520 LONGVIEW ST STE 211
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-4201
Practice Address - Country:US
Practice Address - Phone:512-522-7793
Practice Address - Fax:818-484-2316
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86316133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered