Healthcare Provider Details

I. General information

NPI: 1477474252
Provider Name (Legal Business Name): MYA NICOLE DE LA TORRE MS,RD,LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N CHARLES ST APT 4
BALTIMORE MD
21201-5307
US

IV. Provider business mailing address

801 N CHARLES ST APT 4
BALTIMORE MD
21201-5307
US

V. Phone/Fax

Practice location:
  • Phone: 201-937-0174
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX7802
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: