Healthcare Provider Details

I. General information

NPI: 1861086985
Provider Name (Legal Business Name): WAZOBIAN HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9244 E HAMPTON DR STE 204
CAPITOL HEIGHTS MD
20743-3830
US

IV. Provider business mailing address

2601 PARK CENTER DR APT C703
ALEXANDRIA VA
22302-1477
US

V. Phone/Fax

Practice location:
  • Phone: 240-473-2955
  • Fax:
Mailing address:
  • Phone: 240-751-0691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: ADANNA IBE
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: RDN
Phone: 240-751-0591