MEDICARE: MARISA BROOKE FAIBISH MS, RD, CSSD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	277028	KY
2	133VN1501X	Sports Dietetics Nutrition Registered Dietitian	L007094	NC

General Provider Information

NPI Number	:	1114644937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISA BROOKE FAIBISH MS, RD, CSSD

Provider Business Mailing Address
First Line	:	2719 SHEILA DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-1717
Country	:	US
Telephone Number	:	954-598-3112
Fax Number	:

Provider Business Practice Location Address
First Line	:	2719 SHEILA DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40220-1717
Country	:	US
Telephone Number	:	954-598-3112
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2022
Last Update Date	:	12/03/2025

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