Provider Demographics
NPI:1437168812
Name:HERRSTROM, MARY EVELYN (RD, LD/N)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:EVELYN
Last Name:HERRSTROM
Suffix:
Gender:F
Credentials:RD, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6192 LANSDOWNE CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-5103
Mailing Address - Country:US
Mailing Address - Phone:561-734-8069
Mailing Address - Fax:
Practice Address - Street 1:7700 W CAMINO REAL STE N300
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5576
Practice Address - Country:US
Practice Address - Phone:561-362-8377
Practice Address - Fax:561-416-1460
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
FLND0002210133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered