=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437736113
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE INSIDE NUTRITION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2021
-----------------------------------------------------
Last Update Date | 09/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12409 BUTLER DR NW
-----------------------------------------------------
City | LAVALE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21502-6027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-268-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12409 BUTLER DR NW
-----------------------------------------------------
City | LAVALE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21502-6027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-268-2302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED NUTRITION SPECIALIST
-----------------------------------------------------
Name | EMILY S CERDA
-----------------------------------------------------
Credential | CNS, LDN
-----------------------------------------------------
Telephone | 301-338-8859
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------