Provider Demographics
NPI:1881378503
Name:URENA, MARY MICHELLE (RDN)
Entity type:Individual
Prefix:
First Name:MARY MICHELLE
Middle Name:
Last Name:URENA
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:MARY MICHELLE
Other - Middle Name:
Other - Last Name:HICIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:8524 EDGEWATER PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3402 N 22ND ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-1214
Practice Address - Country:US
Practice Address - Phone:347-858-3258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6101-69918133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education