Provider Demographics
NPI:1851162846
Name:KREILICH, MARY ELISE (MS, RD/N, CSR, LD/N)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISE
Last Name:KREILICH
Suffix:
Gender:F
Credentials:MS, RD/N, CSR, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 LAKE DEESON WOODS LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-7650
Mailing Address - Country:US
Mailing Address - Phone:225-802-4356
Mailing Address - Fax:
Practice Address - Street 1:1002 LAKE DEESON WOODS LN
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-7650
Practice Address - Country:US
Practice Address - Phone:225-802-4356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-10
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND6108133VN1005X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal