Healthcare Provider Details

I. General information

NPI: 1275894339
Provider Name (Legal Business Name): KENDRA MICHELLE VALLE RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 RESEARCH BLVD SUITE 330
ROCKVILLE MD
20850-3215
US

IV. Provider business mailing address

12540 HORSESHOE BEND CIR
CLARKSBURG MD
20871-9396
US

V. Phone/Fax

Practice location:
  • Phone: 240-912-6025
  • Fax: 240-912-6130
Mailing address:
  • Phone: 240-602-6225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX3219
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: