Provider Demographics
NPI:1457688921
Name:KENT, MARISSA ANNE (MS, RD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ANNE
Last Name:KENT
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 VIA MAGNOLIA
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1439
Mailing Address - Country:US
Mailing Address - Phone:949-378-1047
Mailing Address - Fax:949-215-2486
Practice Address - Street 1:26461 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6377
Practice Address - Country:US
Practice Address - Phone:949-378-1047
Practice Address - Fax:949-215-2486
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA928627133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered