Healthcare Provider Details

I. General information

NPI: 1801428412
Provider Name (Legal Business Name): WILDCRAFTED WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2020
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5415 W CEDAR LN STE 202A
BETHESDA MD
20814-1515
US

IV. Provider business mailing address

7010 CHERRY AVE
TAKOMA PARK MD
20912-6445
US

V. Phone/Fax

Practice location:
  • Phone: 301-530-0800
  • Fax:
Mailing address:
  • Phone: 410-688-9009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: KAITLIN MARIE COSTELLO
Title or Position: NUTRITIONIST
Credential: CNS
Phone: 410-688-9009