Provider Demographics
NPI:1003574385
Name:BURKE, AUDREY JANICE (MS, CNS, LDN)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:JANICE
Last Name:BURKE
Suffix:
Gender:F
Credentials:MS, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3939 ROLAND AVE APT 213
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2048
Mailing Address - Country:US
Mailing Address - Phone:617-327-1073
Mailing Address - Fax:
Practice Address - Street 1:3939 ROLAND AVE APT 213
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211-2048
Practice Address - Country:US
Practice Address - Phone:617-327-1073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5385133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education