Provider Demographics
NPI:1356901433
Name:MARK, MARY KATHERINE (MS, MPH, RD, LD/N)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:MARK
Suffix:
Gender:F
Credentials:MS, MPH, RD, LD/N
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:
Other - Last Name:MARK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1680 MICHIGAN AVE STE 700
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-2551
Mailing Address - Country:US
Mailing Address - Phone:305-469-1416
Mailing Address - Fax:
Practice Address - Street 1:1680 MICHIGAN AVE STE 700
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-2551
Practice Address - Country:US
Practice Address - Phone:305-469-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered