Provider Demographics
NPI:1083708291
Name:DE LARA, SUELITA REYES (RDLDMS CNS)
Entity Type:Individual
Prefix:MISS
First Name:SUELITA
Middle Name:REYES
Last Name:DE LARA
Suffix:
Gender:F
Credentials:RDLDMS CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 MARLEIGH CIR
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2205
Mailing Address - Country:US
Mailing Address - Phone:410-605-7629
Mailing Address - Fax:410-605-7691
Practice Address - Street 1:1012 MARLEIGH CIR
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2205
Practice Address - Country:US
Practice Address - Phone:410-605-7629
Practice Address - Fax:410-605-7691
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR369988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR369988OtherREGISTERED DIETITIAN