Healthcare Provider Details

I. General information

NPI: 1568909331
Provider Name (Legal Business Name): REBECCA RIDENOUR RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2017
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MONTCLAIRE AVE SUITE A
FREDERICK MD
21701-4577
US

IV. Provider business mailing address

700 MONTCLAIRE AVE SUITE A
FREDERICK MD
21701-4577
US

V. Phone/Fax

Practice location:
  • Phone: 301-580-0008
  • Fax:
Mailing address:
  • Phone: 301-580-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX3143
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: