Healthcare Provider Details

I. General information

NPI: 1265155337
Provider Name (Legal Business Name): JUNO WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

492 ELDEN ST
HERNDON VA
20170-4513
US

IV. Provider business mailing address

492 ELDEN ST
HERNDON VA
20170-4513
US

V. Phone/Fax

Practice location:
  • Phone: 703-775-4000
  • Fax:
Mailing address:
  • Phone: 703-775-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTINA PESTANA
Title or Position: NUTRITION DIRECTOR
Credential: CNS, LDN
Phone: 703-775-4000