Provider Demographics
NPI:1902220692
Name:PEDIATRIC NUTRITION SUPPORT
Entity Type:Organization
Organization Name:PEDIATRIC NUTRITION SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHEREE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LD
Authorized Official - Phone:703-727-6100
Mailing Address - Street 1:38731 RICKARD RD
Mailing Address - Street 2:
Mailing Address - City:LOVETTSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20180-3115
Mailing Address - Country:US
Mailing Address - Phone:703-727-6100
Mailing Address - Fax:
Practice Address - Street 1:38731 RICKARD RD
Practice Address - Street 2:
Practice Address - City:LOVETTSVILLE
Practice Address - State:VA
Practice Address - Zip Code:20180-3115
Practice Address - Country:US
Practice Address - Phone:703-727-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV633252Y00000X
VA676968252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency