Provider Demographics
NPI:1811456502
Name:CLEMSON, MARIN (RD)
Entity type:Individual
Prefix:
First Name:MARIN
Middle Name:
Last Name:CLEMSON
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 1:2500 W UTOPIA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4172
Mailing Address - Country:US
Mailing Address - Phone:623-683-4462
Mailing Address - Fax:623-683-4963
Practice Address - Street 1:10210 N 92ND ST STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4523
Practice Address - Country:US
Practice Address - Phone:480-882-7460
Practice Address - Fax:480-391-3898
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86065552133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered