Provider Demographics
NPI:1629154273
Name:WARD, MARIE LATENDRESSE (MS, RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:LATENDRESSE
Last Name:WARD
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-4221
Mailing Address - Country:US
Mailing Address - Phone:252-338-4370
Mailing Address - Fax:252-337-7911
Practice Address - Street 1:711 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-5643
Practice Address - Country:US
Practice Address - Phone:252-338-4370
Practice Address - Fax:252-337-7911
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002954133V00000X
TN1554133V00000X
TN00515071133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN515071OtherAMERICAN DIETETIC ASSOC.
NC0932-6070OtherCERTIFIED DIABETES EDUCAT
NCL002954OtherLICENSED DIETITIAN
TN1554OtherLICENSED DIETITIAN
NCL002954OtherLICENSED DIETITIAN