Healthcare Provider Details

I. General information

NPI: 1801258298
Provider Name (Legal Business Name): CARLY ELIZABETH BRAGG RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5999 STEVENSON AVE STE 405
ALEXANDRIA VA
22304-3302
US

IV. Provider business mailing address

PO BOX 1833
ASHBURN VA
20146-1833
US

V. Phone/Fax

Practice location:
  • Phone: 703-552-2722
  • Fax: 703-564-8567
Mailing address:
  • Phone: 703-552-2722
  • Fax: 703-564-8567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: