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NPI Code Detail

MEDICARE: MISS MARY DALE CORNETTA LDN, RD

MEDICARE: MISS MARY DALE CORNETTA LDN, RD
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
1133V00000XRegistered Dietitian1735LA

General Provider Information

NPI Number : 1134114242
Entity Type Code : Individual
Provider Name (Legal Business Name) : MISS MARY DALE CORNETTA LDN, RD
Provider Business Mailing Address
First Line : 3100 DEBORAH DR
Second Line :
City : MONROE
State : LA
Zip : 71201-2092
Country : US
Telephone Number : 318-537-3058
Fax Number : 318-327-4941
Provider Business Practice Location Address
First Line : 309 JACKSON ST
Second Line :
City : MONROE
State : LA
Zip : 71201-7407
Country : US
Telephone Number : 318-327-4072
Fax Number : 318-327-4941
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/14/2005
Last Update Date : 07/08/2007

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