Healthcare Provider Details

I. General information

NPI: 1528639978
Provider Name (Legal Business Name): KSSENTIAL NUTRITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10665 STANHAVEN PL STE 300A
WHITE PLAINS MD
20695-3069
US

IV. Provider business mailing address

10665 STANHAVEN PL STE 300A
WHITE PLAINS MD
20695-3069
US

V. Phone/Fax

Practice location:
  • Phone: 301-848-6020
  • Fax: 301-936-1883
Mailing address:
  • Phone: 301-848-6020
  • Fax: 301-936-1883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: KANWAL MANSUR
Title or Position: CLINICAL NUTRITIONIST
Credential: MS,CNS,LDN,MBBS
Phone: 240-460-8290