Provider Demographics
NPI:1588795611
Name:SQUIRES, MARY (RD, CD, CDCES)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:RD, CD, CDCES
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:STALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD, CDE
Mailing Address - Street 1:PO BOX 211699
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-3699
Mailing Address - Country:US
Mailing Address - Phone:866-849-0692
Mailing Address - Fax:
Practice Address - Street 1:20405 STATE HIGHWAY 249 STE 325
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-2893
Practice Address - Country:US
Practice Address - Phone:866-849-0692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10234830133V00000X
TXDT88969133V00000X
HI399-LD133V00000X
WADI00001620133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8403933OtherDSHS#
WAQ19851Medicare UPIN
WA8403933OtherDSHS#