Provider Demographics
NPI:1760159701
Name:MENKE, MARIELLE (RDN)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:
Last Name:MENKE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 JUPITER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-1872
Mailing Address - Country:US
Mailing Address - Phone:616-375-8450
Mailing Address - Fax:
Practice Address - Street 1:645 CRENSHAW RD
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:AL
Practice Address - Zip Code:35051-3277
Practice Address - Country:US
Practice Address - Phone:866-445-0366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3339133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered