Provider Demographics
NPI:1437168168
Name:MCLIN, MARISA JO (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:JO
Last Name:MCLIN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GLENNS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-2473
Mailing Address - Country:US
Mailing Address - Phone:502-564-9785
Mailing Address - Fax:502-564-9640
Practice Address - Street 1:100 GLENNS CREEK RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-2473
Practice Address - Country:US
Practice Address - Phone:502-564-9785
Practice Address - Fax:502-564-9640
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-05-1860133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered