Provider Demographics
NPI:1336791250
Name:MARX, NITSALA PHITSAMAY (MS, RD)
Entity Type:Individual
Prefix:
First Name:NITSALA
Middle Name:PHITSAMAY
Last Name:MARX
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-1063 MEAHALE PL
Mailing Address - Street 2:
Mailing Address - City:WAIPAHU
Mailing Address - State:HI
Mailing Address - Zip Code:96797-4024
Mailing Address - Country:US
Mailing Address - Phone:808-429-5330
Mailing Address - Fax:
Practice Address - Street 1:94-315 LEONUI ST STE 205
Practice Address - Street 2:
Practice Address - City:WAIPAHU
Practice Address - State:HI
Practice Address - Zip Code:96797-2370
Practice Address - Country:US
Practice Address - Phone:808-429-5330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-11
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI895937133V00000X
HI227-LD133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered