Healthcare Provider Details

I. General information

NPI: 1366557670
Provider Name (Legal Business Name): AUDREY DAGMAR TOMERLIN RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST CMSC B100
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

329 HOMELAND SOUTHWAY APT 1A
BALTIMORE MD
21212-4121
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-6716
  • Fax: 410-614-6929
Mailing address:
  • Phone: 410-433-1619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX2436
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: