Healthcare Provider Details

I. General information

NPI: 1083524342
Provider Name (Legal Business Name): JACQUELYN MAINELLI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 N 53RD AVE
PHOENIX AZ
85031-3046
US

IV. Provider business mailing address

30 W SPRING ST
ALEXANDRIA VA
22301-2451
US

V. Phone/Fax

Practice location:
  • Phone: 623-245-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: