Healthcare Provider Details

I. General information

NPI: 1992195887
Provider Name (Legal Business Name): MARY BEMBENEK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2015
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 EXECUTIVE PARK AVE STE 300A
FAIRFAX VA
22031-2228
US

IV. Provider business mailing address

8500 EXECUTIVE PARK AVE STE 300A
FAIRFAX VA
22031-2228
US

V. Phone/Fax

Practice location:
  • Phone: 703-698-7117
  • Fax:
Mailing address:
  • Phone: 703-698-7117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX3614
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: