Provider Demographics
NPI:1558859215
Name:PIZZOLATTO, MARIE CAROL (RD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:CAROL
Last Name:PIZZOLATTO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:CAROL
Other - Last Name:DOMANGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:619 S FLEISHEL AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2004
Mailing Address - Country:US
Mailing Address - Phone:903-606-5800
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE STE 206
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-606-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
TXDT86016133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT86016OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION