Provider Demographics
NPI:1558513234
Name:BANEVEDES, MARY ELLEN (RDN, CDCES)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:BANEVEDES
Suffix:
Gender:F
Credentials:RDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 TEAKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-7230
Mailing Address - Country:US
Mailing Address - Phone:559-572-2990
Mailing Address - Fax:877-655-6301
Practice Address - Street 1:101 N IRWIN ST STE 205A
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4579
Practice Address - Country:US
Practice Address - Phone:559-572-2990
Practice Address - Fax:877-655-6301
Is Sole Proprietor?:No
Enumeration Date:2008-10-14
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
836115133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered