Provider Demographics
NPI:1710926274
Name:EVERETT, MARCIA LYNN (RD)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:LYNN
Last Name:EVERETT
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 1:1329 19TH ST
Mailing Address - Street 2:C
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1946
Mailing Address - Country:US
Mailing Address - Phone:310-428-6376
Mailing Address - Fax:310-268-4944
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-268-3061
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes132700000XDietary & Nutritional Service ProvidersDietary Manager
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA894730OtherDIETETIC REGISTRATION