Provider Demographics
NPI:1053119412
Name:LEGRAND, MARA K (PHD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:K
Last Name:LEGRAND
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14217 SW BARROWS RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97007-6131
Mailing Address - Country:US
Mailing Address - Phone:970-759-1855
Mailing Address - Fax:
Practice Address - Street 1:14217 SW BARROWS RD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-6131
Practice Address - Country:US
Practice Address - Phone:970-759-1855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO133NN1002X, 174H00000X
174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education