Basic Information
| Provider Information | |||||||||
| NPI: | 1962691337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDWARDS | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 301173 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753031173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135003500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6410 FANNIN ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 08/03/2016 | ||||||||
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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 | DT04726 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 8AG689 | 01 | TX | BCBS | OTHER |