Provider Demographics
NPI:1366779969
Name:FISHER, MAURIN KAY (MS, RD, LN)
Entity type:Individual
Prefix:
First Name:MAURIN
Middle Name:KAY
Last Name:FISHER
Suffix:
Gender:F
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1529
Mailing Address - Country:US
Mailing Address - Phone:605-573-0141
Mailing Address - Fax:
Practice Address - Street 1:701 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1529
Practice Address - Country:US
Practice Address - Phone:605-573-0141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered