Provider Demographics
NPI:1760187785
Name:MAZURKIEWICZ, ELENA (RD)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:MAZURKIEWICZ
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 1:37750 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-9088
Mailing Address - Country:US
Mailing Address - Phone:734-626-6417
Mailing Address - Fax:
Practice Address - Street 1:5452 FORT ST STE 200
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-4638
Practice Address - Country:US
Practice Address - Phone:734-642-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86116402133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered