Basic Information
| Provider Information | |||||||||
| NPI: | 1740330794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCMILLION | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | CDCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1680 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257171680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046971396 | ||||||||
| FaxNumber: | 3046972086 | ||||||||
| Practice Location | |||||||||
| Address1: | 408 ALEXANDER STREET | ||||||||
| Address2: | |||||||||
| City: | CEDAR GROVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045951770 | ||||||||
| FaxNumber: | 3045953298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 235 | WV | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.