Provider Demographics
NPI:1558028118
Name:FERNANDES, MARYLOU (RDN)
Entity Type:Individual
Prefix:
First Name:MARYLOU
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 GRAMERCY GDNS
Mailing Address - Street 2:
Mailing Address - City:MIDDLESEX
Mailing Address - State:NJ
Mailing Address - Zip Code:08846-1687
Mailing Address - Country:US
Mailing Address - Phone:908-821-8684
Mailing Address - Fax:
Practice Address - Street 1:73 GRAMERCY GDNS
Practice Address - Street 2:
Practice Address - City:MIDDLESEX
Practice Address - State:NJ
Practice Address - Zip Code:08846-1687
Practice Address - Country:US
Practice Address - Phone:908-821-8684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered