Provider Demographics
NPI:1962127696
Name:PERUSO, MARISA (RDN,LDN)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:
Last Name:PERUSO
Suffix:
Gender:F
Credentials:RDN,LDN
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:
Other - Last Name:PERUSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN,LDN
Mailing Address - Street 1:118 SHAELI DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:PA
Mailing Address - Zip Code:15501-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 SHAELI DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15501-1805
Practice Address - Country:US
Practice Address - Phone:814-443-0158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006331133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN006331Medicaid