Provider Demographics
NPI:1912234691
Name:FERGUSON AYALA, MARIANNE (RD)
Entity Type:Individual
Prefix:MS
First Name:MARIANNE
Middle Name:
Last Name:FERGUSON AYALA
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 1:10508 GIBSONTON DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-5434
Mailing Address - Country:US
Mailing Address - Phone:813-390-2506
Mailing Address - Fax:
Practice Address - Street 1:10508 GIBSONTON DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-5434
Practice Address - Country:US
Practice Address - Phone:813-390-2506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-17
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5177133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLND5177OtherLICENSE