Provider Demographics
NPI:1699345777
Name:SPICKERMAN, MARISSA KAREN (RD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:KAREN
Last Name:SPICKERMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 PLEASANT ST APT 6
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-3489
Mailing Address - Country:US
Mailing Address - Phone:231-245-4555
Mailing Address - Fax:
Practice Address - Street 1:1750 E BELLOWS ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3872
Practice Address - Country:US
Practice Address - Phone:989-953-5804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86119368133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered