Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2019040877 | MO |
NPI | 1225618721 |
---|---|
Provider Name | Wrendy Dawn Marcinik |
First Address | Osage Beach, MO 65065-2158 |
Second Address | Osage Beach, MO 65065-2158 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2021 |
Last Update Date | 09/04/2021 |