Provider Demographics
NPI:1457498958
Name:FARIVARI, MARY LYNN (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:FARIVARI
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 1:2101 EAST JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE 3 WEST ATTN: SANJAY MATHUR-DATA MGMT
Mailing Address - City:ROCVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-7446
Mailing Address - Fax:301-816-7170
Practice Address - Street 1:2100 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3202
Practice Address - Country:US
Practice Address - Phone:202-872-7055
Practice Address - Fax:202-872-7132
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCD1100000130133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
725254OtherRD ID NUMBER