Provider Demographics
NPI:1336769710
Name:MERCHANT, MADONNA RENEE
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:RENEE
Last Name:MERCHANT
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 1:1453 WESTOVER AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1027
Mailing Address - Country:US
Mailing Address - Phone:757-403-0462
Mailing Address - Fax:
Practice Address - Street 1:1453 WESTOVER AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1027
Practice Address - Country:US
Practice Address - Phone:757-403-0462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86007687133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered