Provider Demographics
NPI:1871917112
Name:MARINE, MARY JO (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:MARINE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8776 E. SHEA BLVD.
Mailing Address - Street 2:SUITE 103-304
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260
Mailing Address - Country:US
Mailing Address - Phone:480-634-2985
Mailing Address - Fax:480-634-2987
Practice Address - Street 1:8952 E. DESERT COVE DR.
Practice Address - Street 2:SUITE 114
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260
Practice Address - Country:US
Practice Address - Phone:480-634-2985
Practice Address - Fax:480-634-2987
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ955745133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered