Healthcare Provider Details

I. General information

NPI: 1396091732
Provider Name (Legal Business Name): EMILY WUNDER RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2012
Last Update Date: 08/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 IRVING ST NW
WASHINGTON DC
20010-2921
US

IV. Provider business mailing address

102 IRVING ST NW
WASHINGTON DC
20010-2921
US

V. Phone/Fax

Practice location:
  • Phone: 202-877-1101
  • Fax:
Mailing address:
  • Phone: 202-877-1101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI100000538
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: