Provider Demographics
NPI:1801285408
Name:SCOTT, MARY LUCIA (LD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LUCIA
Last Name:SCOTT
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1479 BLUEBERRY DR
Mailing Address - Street 2:
Mailing Address - City:SNEADS
Mailing Address - State:FL
Mailing Address - Zip Code:32460-4060
Mailing Address - Country:US
Mailing Address - Phone:850-593-6420
Mailing Address - Fax:
Practice Address - Street 1:1479 BLUEBERRY DR
Practice Address - Street 2:
Practice Address - City:SNEADS
Practice Address - State:FL
Practice Address - Zip Code:32460-4060
Practice Address - Country:US
Practice Address - Phone:850-593-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND63133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist