Provider Demographics
NPI:1174247928
Name:TELLO, MARYORI YULDANA (RD, LDN, CDM, CFPP)
Entity type:Individual
Prefix:
First Name:MARYORI
Middle Name:YULDANA
Last Name:TELLO
Suffix:
Gender:F
Credentials:RD, LDN, CDM, CFPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 16TH AVE N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3753
Mailing Address - Country:US
Mailing Address - Phone:954-654-1139
Mailing Address - Fax:
Practice Address - Street 1:850 6TH AVE S STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4256
Practice Address - Country:US
Practice Address - Phone:954-654-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8502133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered