Provider Demographics
NPI:1720304710
Name:SAMPLE, MARILYN L (RD)
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:L
Last Name:SAMPLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:MARILYN
Other - Middle Name:L
Other - Last Name:HAAVISTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:483 W. SEED FARM RD.
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0115
Mailing Address - Country:US
Mailing Address - Phone:602-528-1340
Mailing Address - Fax:602-528-1296
Practice Address - Street 1:483 W. SEED FARM RD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85147-0115
Practice Address - Country:US
Practice Address - Phone:602-258-1340
Practice Address - Fax:602-528-1296
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL685690133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered