Healthcare Provider Details

I. General information

NPI: 1982729117
Provider Name (Legal Business Name): MANDY M COOK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 IRVING ST NW
WASHINGTON DC
20422-0001
US

IV. Provider business mailing address

1226 ELM GROVE CIR
SILVER SPRING MD
20905-7018
US

V. Phone/Fax

Practice location:
  • Phone: 202-745-8190
  • Fax:
Mailing address:
  • Phone: 616-916-4991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number960672
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: