Healthcare Provider Details

I. General information

NPI: 1629154273
Provider Name (Legal Business Name): MARIE LATENDRESSE WARD M.S., R.D., C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 ROANOKE AVE
ELIZABETH CITY NC
27909-5643
US

IV. Provider business mailing address

801 W COLONIAL AVE
ELIZABETH CITY NC
27909-4221
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-4370
  • Fax: 252-337-7911
Mailing address:
  • Phone: 252-338-4370
  • Fax: 252-337-7911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL002954
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1554
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number00515071
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: