Healthcare Provider Details

I. General information

NPI: 1013610807
Provider Name (Legal Business Name): STEPHANIE MISANIK LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/22/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8880 MCGAW RD STE B
COLUMBIA MD
21045-5166
US

IV. Provider business mailing address

9755 LITTLE PATUXENT DR SUITE 100
COLUMBIA MD
21046
US

V. Phone/Fax

Practice location:
  • Phone: 800-762-6282
  • Fax:
Mailing address:
  • Phone: 800-762-6282
  • 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: