Healthcare Provider Details

I. General information

NPI: 1972418648
Provider Name (Legal Business Name): ELISHAH DUBOSE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611F SANGAMORE RD # 107
BETHESDA MD
20816-2545
US

IV. Provider business mailing address

4611F SANGAMORE RD # 107
BETHESDA MD
20816-2545
US

V. Phone/Fax

Practice location:
  • Phone: 406-868-8616
  • Fax:
Mailing address:
  • Phone: 406-868-8616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: