Provider Demographics
NPI:1376814145
Name:DAVIS, MARLENE ROSE (RD/LD)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:ROSE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 COUNTRY LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2320
Mailing Address - Country:US
Mailing Address - Phone:210-828-5487
Mailing Address - Fax:
Practice Address - Street 1:419 COUNTRY LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-2320
Practice Address - Country:US
Practice Address - Phone:210-828-5487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 133VN1005X, 133VN1006X
TXDT05210133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic