Individual
MRS. MARY VIRGINIA MARK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD, LD, CDE
Contact information
Practice address
408 COUNCIL CIRCLE, SUITE C, TUPELO, MS 38801-4949
(662) 377-6334
(662) 377-6330
Mailing address
408 COUNCIL CIRCLE, SUITE C, TUPELO, MS 38801-4949
(662) 377-6334
(662) 377-6330
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
D0804
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
22220310
NATIONAL CERTIFICATION BOARD FOR DIABETES EDUCATORS
—
01
—
860079
COMMISSION OF DIETETIC REGISTRATION
—
01
—
D0804
MISSISSIPPI STATE DEPARTMENT OF HEALTH PROFESSIONAL LICENSURE
MS
Enumeration date
04/19/2018
Last updated
06/16/2018
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