Healthcare Provider Details

I. General information

NPI: 1053949537
Provider Name (Legal Business Name): ESOSA EDOSOMWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 CHAIN BRIDGE RD
FAIRFAX VA
22030-3316
US

IV. Provider business mailing address

3970 CHAIN BRIDGE RD
FAIRFAX VA
22030-3316
US

V. Phone/Fax

Practice location:
  • Phone: 202-643-5703
  • Fax:
Mailing address:
  • Phone: 202-643-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX4886
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: