Healthcare Provider Details

I. General information

NPI: 1952058810
Provider Name (Legal Business Name): REBECCA FULP-EICKSTAEDT CNS, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8303 ARLINGTON BLVD STE 110
FAIRFAX VA
22031-2903
US

IV. Provider business mailing address

8303 ARLINGTON BLVD STE 110
FAIRFAX VA
22031-2903
US

V. Phone/Fax

Practice location:
  • Phone: 571-257-3378
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX5414
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number18336
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: