Healthcare Provider Details

I. General information

NPI: 1154854545
Provider Name (Legal Business Name): SUSANNAH LIN EDWARDS MS RDN LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2017
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10215 FERNWOOD RD SUITE 630
BETHESDA MD
20817-1106
US

IV. Provider business mailing address

1707 BLACK OAK LN
SILVER SPRING MD
20910-1423
US

V. Phone/Fax

Practice location:
  • Phone: 240-449-3094
  • Fax: 240-489-4415
Mailing address:
  • Phone: 240-449-3094
  • Fax: 240-489-4415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX4187
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: