Healthcare Provider Details

I. General information

NPI: 1013950716
Provider Name (Legal Business Name): MARILYN CUNNINGHAM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARILYN ANDERS RD

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 09/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 PROVIDENCE DR E TOWER, SUITE 3030
ANCHORAGE AK
99508-4615
US

IV. Provider business mailing address

PO BOX 4105
PORTLAND OR
97208-4105
US

V. Phone/Fax

Practice location:
  • Phone: 907-212-7980
  • Fax: 907-212-7981
Mailing address:
  • Phone: 866-907-1068
  • Fax: 425-917-9141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number637378
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number308
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: