Provider Demographics
NPI:1871675710
Name:DAHL, MARILYN KAY (RD, MBA, LD/N)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:KAY
Last Name:DAHL
Suffix:
Gender:F
Credentials:RD, MBA, LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 DUVAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:904-285-4912
Mailing Address - Fax:
Practice Address - Street 1:2380 3RD ST S STE 2
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-8038
Practice Address - Country:US
Practice Address - Phone:904-270-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND546133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered