Provider Demographics
NPI:1467797100
Name:MARINA STAUFFER, REGISTERED DIETITIAN, CERTIFIED DIETITIAN NUTRITIONIS
Entity Type:Organization
Organization Name:MARINA STAUFFER, REGISTERED DIETITIAN, CERTIFIED DIETITIAN NUTRITIONIS
Other - Org Name:MARINA STAUFFER, RD, CDN, PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:STAUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:RD, CDN
Authorized Official - Phone:631-374-6371
Mailing Address - Street 1:44 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2945
Mailing Address - Country:US
Mailing Address - Phone:631-374-6371
Mailing Address - Fax:
Practice Address - Street 1:694 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3147
Practice Address - Country:US
Practice Address - Phone:631-374-6371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007284-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty