Healthcare Provider Details

I. General information

NPI: 1568937191
Provider Name (Legal Business Name): VIRGINIA KAY MIRENZI RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 MEDICAL PKWY STE 510
ANNAPOLIS MD
21401-3747
US

IV. Provider business mailing address

620 SAMANTHA DRIVE
ANNAPOLIS MD
21401
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1230
  • Fax:
Mailing address:
  • Phone: 410-544-0653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD00709
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: