Healthcare Provider Details

I. General information

NPI: 1346679644
Provider Name (Legal Business Name): BRANDY MICHELLE MSALL RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8118 GOOD LUCK RD
LANHAM MD
20706-3574
US

IV. Provider business mailing address

8118 GOOD LUCK RD
LANHAM MD
20706
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-7970
  • Fax:
Mailing address:
  • Phone: 301-552-7970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX3487
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86019915
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: