Provider Demographics
NPI:1396783759
Name:PANGANIBAN, MARILYN E (LD/N)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:E
Last Name:PANGANIBAN
Suffix:
Gender:F
Credentials:LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 6TH ST
Mailing Address - Street 2:MC #24
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4324
Mailing Address - Country:US
Mailing Address - Phone:904-665-2410
Mailing Address - Fax:904-630-3316
Practice Address - Street 1:2444 MAYPORT RD
Practice Address - Street 2:#12
Practice Address - City:ATLANTIC BEACH
Practice Address - State:FL
Practice Address - Zip Code:32233-6816
Practice Address - Country:US
Practice Address - Phone:904-270-2580
Practice Address - Fax:904-270-2584
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
FLND1062133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8291ZMedicare ID - Type Unspecified