Healthcare Provider Details

I. General information

NPI: 1730001496
Provider Name (Legal Business Name): ASTRID MARISA INNISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9904 VISTA POINTE DR
UPPER MARLBORO MD
20774-3776
US

IV. Provider business mailing address

9904 VISTA POINTE DR
UPPER MARLBORO MD
20774-3776
US

V. Phone/Fax

Practice location:
  • Phone: 512-693-7045
  • Fax:
Mailing address:
  • Phone: 512-693-7045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDX8860
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: