Healthcare Provider Details

I. General information

NPI: 1386719607
Provider Name (Legal Business Name): LISE ANNE GLOEDE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5275 LEE HWY SUITE #101
ARLINGTON VA
22207-1619
US

IV. Provider business mailing address

5275 LEE HWY SUITE #101
ARLINGTON VA
22207-1619
US

V. Phone/Fax

Practice location:
  • Phone: 703-575-1007
  • Fax: 703-358-8703
Mailing address:
  • Phone: 703-575-1007
  • Fax: 703-358-8703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: