Healthcare Provider Details

I. General information

NPI: 1457498958
Provider Name (Legal Business Name): MARY LYNN FARIVARI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 PENNSYLVANIA AVE NW
WASHINGTON DC
20037-3202
US

IV. Provider business mailing address

2101 EAST JEFFERSON ST KAISER PERMANENTE 3 WEST ATTN: SANJAY MATHUR-DATA MGMT
ROCVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 202-872-7055
  • Fax: 202-872-7132
Mailing address:
  • Phone: 301-816-7446
  • Fax: 301-816-7170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1100000130
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: