Provider Demographics
NPI:1700023959
Name:PELL, MARCIA FASTABEND (RD, LD/N, CDE)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:FASTABEND
Last Name:PELL
Suffix:
Gender:F
Credentials:RD, LD/N, CDE
Other - Prefix:
Other - First Name:MARCIA
Other - Middle Name:FASTABEND
Other - Last Name:LIPSCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD/N
Mailing Address - Street 1:2337 JUDSON ST
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3018
Mailing Address - Country:US
Mailing Address - Phone:850-867-0336
Mailing Address - Fax:
Practice Address - Street 1:2337 JUDSON ST
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-3018
Practice Address - Country:US
Practice Address - Phone:850-867-0336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-09
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 3263133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered