Provider Demographics
NPI:1255956363
Name:AGEE, MARYLAUREN
Entity type:Individual
Prefix:
First Name:MARYLAUREN
Middle Name:
Last Name:AGEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 WORKMAN DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38256-4345
Mailing Address - Country:US
Mailing Address - Phone:865-255-4885
Mailing Address - Fax:
Practice Address - Street 1:120 WORKMAN DR
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:TN
Practice Address - Zip Code:38256-4345
Practice Address - Country:US
Practice Address - Phone:865-255-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86176093133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered