Provider Demographics
NPI:1639141336
Name:PENNINGTON, MARY BETH (RD,LD/N)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:RD,LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2080 CHILD ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32214-5005
Mailing Address - Country:US
Mailing Address - Phone:912-573-4731
Mailing Address - Fax:912-573-4229
Practice Address - Street 1:2080 CHILD ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-5005
Practice Address - Country:US
Practice Address - Phone:912-573-4731
Practice Address - Fax:912-573-4229
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2733133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered