Healthcare Provider Details

I. General information

NPI: 1194638494
Provider Name (Legal Business Name): SAM PURCELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1143 DEAN ST # 3
BROOKLYN NY
11216-3088
US

IV. Provider business mailing address

1143 DEAN ST # 3
BROOKLYN NY
11216-3088
US

V. Phone/Fax

Practice location:
  • Phone: 301-312-3260
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD1200001896
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: