Provider Demographics
NPI:1710426713
Name:ELIASON, MARIE (RD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:ELIASON
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 1:3553 ATLANTIC AVE # 553
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-5606
Mailing Address - Country:US
Mailing Address - Phone:562-294-4737
Mailing Address - Fax:
Practice Address - Street 1:3553 ATLANTIC AVE # 553
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-5606
Practice Address - Country:US
Practice Address - Phone:480-447-0624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2023-10-19
Deactivation Date:2018-01-24
Deactivation Code:
Reactivation Date:2019-09-11
Provider Licenses
StateLicense IDTaxonomies
CA1064813133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered