Provider Demographics
NPI:1578167235
Name:ENGELHARDT, MARISSA L (RDN)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:L
Last Name:ENGELHARDT
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 1:555 LINN ST
Mailing Address - Street 2:
Mailing Address - City:ALLEGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49010-1524
Mailing Address - Country:US
Mailing Address - Phone:989-450-6276
Mailing Address - Fax:
Practice Address - Street 1:555 LINN ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-1524
Practice Address - Country:US
Practice Address - Phone:269-686-4251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86098171133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered