Basic Information
| Provider Information | |||||||||
| NPI: | 1023512704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UPTON | ||||||||
| FirstName: | MISKA | ||||||||
| MiddleName: | MARET | ||||||||
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| Credential: | BS, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1014 8TH AVE N | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322503596 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6210 BEACH BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322162706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043458100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.