Provider Demographics
NPI:1932563368
Name:MARCOUX, AUDREY (RD)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MARCOUX
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 1:1020 MARY ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-1930
Mailing Address - Country:US
Mailing Address - Phone:315-724-6907
Mailing Address - Fax:315-733-0791
Practice Address - Street 1:10708 N GAGE RD
Practice Address - Street 2:
Practice Address - City:BARNEVELD
Practice Address - State:NY
Practice Address - Zip Code:13304-2527
Practice Address - Country:US
Practice Address - Phone:315-896-2654
Practice Address - Fax:315-896-2717
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000901OtherLICENSE