Provider Demographics
NPI:1720832165
Name:OLSON, MARIELLE ANTOINETTE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:MARIELLE
Middle Name:ANTOINETTE
Last Name:OLSON
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2078 KING ARTHUR CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-6059
Mailing Address - Country:US
Mailing Address - Phone:636-368-6432
Mailing Address - Fax:
Practice Address - Street 1:12303 DEPAUL DRIVE
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63044
Practice Address - Country:US
Practice Address - Phone:144-447-5663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021035174133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered