Provider Demographics
NPI:1689794901
Name:MASON, MARYLYNNE Q (RD)
Entity Type:Individual
Prefix:MS
First Name:MARYLYNNE
Middle Name:Q
Last Name:MASON
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 1:415 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-4730
Mailing Address - Country:US
Mailing Address - Phone:920-206-8488
Mailing Address - Fax:920-206-8491
Practice Address - Street 1:415 S 8TH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-4730
Practice Address - Country:US
Practice Address - Phone:920-206-8488
Practice Address - Fax:920-206-8491
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI411-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0004000071750Medicare ID - Type UnspecifiedMEDICARE PART B-WPS