Provider Demographics
NPI:1053551325
Name:PRUITT, MARISA A (RD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:A
Last Name:PRUITT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:A
Other - Last Name:SILBERNAGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1836 SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5429
Mailing Address - Country:US
Mailing Address - Phone:608-782-7300
Mailing Address - Fax:
Practice Address - Street 1:1836 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-5429
Practice Address - Country:US
Practice Address - Phone:608-782-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-26
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered