Provider Demographics
NPI:1174759104
Name:MCGERVEY, MARYANNA SCHADE (MPH, RD)
Entity type:Individual
Prefix:
First Name:MARYANNA
Middle Name:SCHADE
Last Name:MCGERVEY
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24531 VIA TONADA
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24531 VIA TONADA
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2027
Practice Address - Country:US
Practice Address - Phone:949-690-9132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2023-02-23
Deactivation Date:2021-04-21
Deactivation Code:
Reactivation Date:2023-02-23
Provider Licenses
StateLicense IDTaxonomies
CA971023133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered