Provider Demographics
NPI:1497242911
Name:MARK, MARY VIRGINIA (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:VIRGINIA
Last Name:MARK
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Gender:F
Credentials:RD, LD, CDE
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Mailing Address - Street 1:408 COUNCIL CIRCLE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-4949
Mailing Address - Country:US
Mailing Address - Phone:662-377-6334
Mailing Address - Fax:662-377-6330
Practice Address - Street 1:408 COUNCIL CIRCLE
Practice Address - Street 2:SUITE C
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-4949
Practice Address - Country:US
Practice Address - Phone:662-377-6334
Practice Address - Fax:662-377-6330
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2018-06-16
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Provider Licenses
StateLicense IDTaxonomies
MSD0804133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
22220310OtherNATIONAL CERTIFICATION BOARD FOR DIABETES EDUCATORS
MSD0804OtherMISSISSIPPI STATE DEPARTMENT OF HEALTH PROFESSIONAL LICENSURE
860079OtherCOMMISSION OF DIETETIC REGISTRATION