MEDICARE: ELLEN AVERY MS, RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1004X	Pediatric Nutrition Registered Dietitian
2	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1033461363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN AVERY MS, RD

Provider Business Mailing Address
First Line	:	7640 TREMAYNE PL APT 102
Second Line	:
City	:	MC LEAN
State	:	VA
Zip	:	22102-7640
Country	:	US
Telephone Number	:	540-295-0180
Fax Number	:

Provider Business Practice Location Address
First Line	:	7640 TREMAYNE PL APT 102
Second Line	:
City	:	MC LEAN
State	:	VA
Zip	:	22102-7640
Country	:	US
Telephone Number	:	540-295-0180
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2012
Last Update Date	:	01/13/2026

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