Provider Demographics
NPI:1386703643
Name:WIRTH, MARCIA ANN (DIETICIAN)
Entity type:Individual
Prefix:MS
First Name:MARCIA
Middle Name:ANN
Last Name:WIRTH
Suffix:
Gender:F
Credentials:DIETICIAN
Other - Prefix:MS
Other - First Name:MARCIA
Other - Middle Name:ANN
Other - Last Name:DEMAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DIETICIAN
Mailing Address - Street 1:600 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1091
Mailing Address - Country:US
Mailing Address - Phone:309-944-6431
Mailing Address - Fax:
Practice Address - Street 1:600 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1091
Practice Address - Country:US
Practice Address - Phone:309-944-6431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL716443133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
L97967Medicare ID - Type Unspecified