Provider Demographics
NPI:1801387170
Name:STACK, MARISA IRENE (RD/LDN)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:IRENE
Last Name:STACK
Suffix:
Gender:F
Credentials:RD/LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7862 NW 172ND ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7862 NW 172ND ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-3849
Practice Address - Country:US
Practice Address - Phone:305-877-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8188133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered