Healthcare Provider Details

I. General information

NPI: 1669018594
Provider Name (Legal Business Name): MARYBETH PECINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2019
Last Update Date: 11/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 E 38TH ST
MARION IN
46953-4568
US

IV. Provider business mailing address

202 DORAL PARK DR
KOKOMO IN
46901-7016
US

V. Phone/Fax

Practice location:
  • Phone: 765-674-3321
  • Fax:
Mailing address:
  • Phone: 765-434-3289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR659638
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: