Healthcare Provider Details

I. General information

NPI: 1407188428
Provider Name (Legal Business Name): TAMELA JEANINE MACK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2010
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 PEABODY STREET NORTHEAST
WASHINGTON DC
20011-1645
US

IV. Provider business mailing address

417 PEABODY STREET NORTHEAST
WASHINGTON DC
20011-1645
US

V. Phone/Fax

Practice location:
  • Phone: 202-529-0582
  • Fax: 202-529-0220
Mailing address:
  • Phone: 202-529-0582
  • Fax: 202-529-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND3748
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDO2317
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI682
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: