=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932795093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APPETITE 4 CHANGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2020
-----------------------------------------------------
Last Update Date | 12/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 644 BURNSIDE TER SE
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20175-8936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-577-8683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 644 BURNSIDE TER SE
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20175-8936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-577-8683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED NUTRITIONIST/PRESIDENT
-----------------------------------------------------
Name | MRS. TAMEKIA F LEWIS
-----------------------------------------------------
Credential | CN
-----------------------------------------------------
Telephone | 571-577-8683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------