Healthcare Provider Details

I. General information

NPI: 1376883009
Provider Name (Legal Business Name): MARILYN ELIZABETH MIQUEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2013
Last Update Date: 02/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2531 TRENTON AVE UNIT 103
PHILADELPHIA PA
19125-1730
US

IV. Provider business mailing address

2531 TRENTON AVE UNIT 103
PHILADELPHIA PA
19125-1730
US

V. Phone/Fax

Practice location:
  • Phone: 908-268-2087
  • Fax:
Mailing address:
  • Phone: 908-268-2087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86007534
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: