Healthcare Provider Details

I. General information

NPI: 1033241708
Provider Name (Legal Business Name): ILSE O'BRIEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 LOISDALE CT
SPRINGFIELD VA
22150-1826
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-1000
  • Fax: 301-816-7170
Mailing address:
  • Phone: 301-816-7405
  • Fax: 301-388-1740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number609194
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: