Healthcare Provider Details

I. General information

NPI: 1912632183
Provider Name (Legal Business Name): BROOKE WURSTER RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 RAVINES EDGE CT STE 301
COLUMBUS OH
43235-5423
US

IV. Provider business mailing address

3713 WINDWARD WAY APT 101
COLUMBUS OH
43204-1564
US

V. Phone/Fax

Practice location:
  • Phone: 888-364-5977
  • Fax:
Mailing address:
  • Phone: 727-580-5175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.09836
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: