Provider Demographics
NPI:1982238143
Name:VAN ZILE, MARCY (RDN)
Entity type:Individual
Prefix:
First Name:MARCY
Middle Name:
Last Name:VAN ZILE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:MARCY
Other - Middle Name:
Other - Last Name:VAN ZILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 AVON RD
Mailing Address - Street 2:
Mailing Address - City:PINE BEACH
Mailing Address - State:NJ
Mailing Address - Zip Code:08741-1058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 AVON RD
Practice Address - Street 2:
Practice Address - City:PINE BEACH
Practice Address - State:NJ
Practice Address - Zip Code:08741-1058
Practice Address - Country:US
Practice Address - Phone:732-691-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL812076133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL812076OtherCOMMISION ON DIETETIC REGISTRATION