Healthcare Provider Details

I. General information

NPI: 1841797131
Provider Name (Legal Business Name): CARLEE MOELLER DIETITIAN CONSULTANT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 04/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7001 W BROAD ST
RICHMOND VA
23294-3701
US

IV. Provider business mailing address

4933 SADLER GLEN CT
GLEN ALLEN VA
23060-6171
US

V. Phone/Fax

Practice location:
  • Phone: 804-714-6381
  • Fax:
Mailing address:
  • Phone: 804-714-6381
  • Fax: 804-672-7919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number992809
License Number StateWA

VIII. Authorized Official

Name: CARLEE MOELLER
Title or Position: REGISTERED DIETITIAN
Credential: R.D.
Phone: 805-714-6381