Healthcare Provider Details

I. General information

NPI: 1881378503
Provider Name (Legal Business Name): MARY MICHELLE URENA RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY MICHELLE HICIANO RDN

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3402 N 22ND ST
TAMPA FL
33605-1214
US

IV. Provider business mailing address

8524 EDGEWATER PLACE BLVD
TAMPA FL
33615-1390
US

V. Phone/Fax

Practice location:
  • Phone: 347-858-3258
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number6101-69918
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number6101-69918
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: