Healthcare Provider Details

I. General information

NPI: 1578679387
Provider Name (Legal Business Name): ELLEN MARIE BOSLEY MBA, MS, RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELLEN MARIE GREEN MBA, MS, RD

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 VERMONT AVE NW
WASHINGTON DC
20420-0001
US

IV. Provider business mailing address

9490 VIRGINIA CENTER BOULEVARD, UNIT 442
VIENNA VA
22181-4802
US

V. Phone/Fax

Practice location:
  • Phone: 202-273-7868
  • Fax: 202-273-9148
Mailing address:
  • Phone: 202-273-7868
  • Fax: 202-273-9148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberR483239
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: