Provider Demographics
NPI:1356932297
Name:ETHIER, MARYSE S (RD)
Entity type:Individual
Prefix:
First Name:MARYSE
Middle Name:S
Last Name:ETHIER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3841 BASILONE ST UNIT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5409
Mailing Address - Country:US
Mailing Address - Phone:706-830-1159
Mailing Address - Fax:
Practice Address - Street 1:3841 BASILONE ST UNIT 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5409
Practice Address - Country:US
Practice Address - Phone:706-830-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86115712133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
86115712OtherCDR