Provider Demographics
NPI:1184599029
Name:BURNSIDE, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 OLD SYCAMORE LOOP
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4450 OLD SYCAMORE LOOP
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5357
Practice Address - Country:US
Practice Address - Phone:813-220-8924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-09
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7559133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered