Provider Demographics
NPI:1407131519
Name:MAXWELL, MARJORIE D (RD)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:D
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-851-3307
Mailing Address - Fax:314-647-7967
Practice Address - Street 1:1027 BELLEVUE AVE
Practice Address - Street 2:SUITE 107
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1851
Practice Address - Country:US
Practice Address - Phone:314-851-3307
Practice Address - Fax:314-647-7967
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025981133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered