Healthcare Provider Details

I. General information

NPI: 1891300190
Provider Name (Legal Business Name): MORGAN HOLL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20130 LAKEVIEW CENTER PLZ
ASHBURN VA
20147-5904
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 Code133V00000X
TaxonomyRegistered Dietitian
License Number86173621
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: