Healthcare Provider Details

I. General information

NPI: 1184599029
Provider Name (Legal Business Name): MARISSA BURNSIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 OLD SYCAMORE LOOP
WINTER GARDEN FL
34787-5357
US

IV. Provider business mailing address

4450 OLD SYCAMORE LOOP
WINTER GARDEN FL
34787-5357
US

V. Phone/Fax

Practice location:
  • Phone: 813-220-8924
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number7559
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: