=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700023959
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCIA FASTABEND PELL RD, LD/N, CDE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2009
-----------------------------------------------------
Last Update Date | 02/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2337 JUDSON ST
-----------------------------------------------------
City | LYNN HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32444-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-867-0336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2337 JUDSON ST
-----------------------------------------------------
City | LYNN HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32444-3018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-867-0336
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | ND 3263
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------