Healthcare Provider Details

I. General information

NPI: 1942165303
Provider Name (Legal Business Name): MERCEDES MARSH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4055 HOGAN DR APT 3602
TYLER TX
75709-6963
US

IV. Provider business mailing address

4055 HOGAN DR APT 3602
TYLER TX
75709-6963
US

V. Phone/Fax

Practice location:
  • Phone: 512-525-0453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86330831
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: