Provider Demographics
NPI:1689049488
Name:BANE, MARISSA (RD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BANE
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 1:13535 NEMOURS PKWY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32827-7402
Mailing Address - Country:US
Mailing Address - Phone:407-567-4000
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7402
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7485133V00000X, 133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered