MEDICARE: GHAIDA AWWAD RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	86051892	MO

General Provider Information

NPI Number	:	1467110320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GHAIDA AWWAD RDN

Provider Business Mailing Address
First Line	:	1012 ROCK CREEK ELEMENTARY SCHOOL DR
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-7576
Country	:	US
Telephone Number	:	314-736-8686
Fax Number	:

Provider Business Practice Location Address
First Line	:	1012 ROCK CREEK ELEMENTARY SCHOOL DR
Second Line	:
City	:	O FALLON
State	:	MO
Zip	:	63366-7576
Country	:	US
Telephone Number	:	314-736-8686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2021
Last Update Date	:	12/07/2021

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