Provider Demographics
NPI:1609649318
Name:KRISCO, MARY PHYLLIS (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:PHYLLIS
Last Name:KRISCO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 E GRAND AVE APT F
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-6262
Mailing Address - Country:US
Mailing Address - Phone:608-490-5283
Mailing Address - Fax:
Practice Address - Street 1:444 E GRAND AVE APT F
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6262
Practice Address - Country:US
Practice Address - Phone:608-490-5283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA110826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered