Provider Demographics
NPI:1306197587
Name:NATHAN, SUCHITRA M (MSRD)
Entity Type:Individual
Prefix:
First Name:SUCHITRA
Middle Name:M
Last Name:NATHAN
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 PROSPERITY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4339
Mailing Address - Country:US
Mailing Address - Phone:703-698-2505
Mailing Address - Fax:703-698-2506
Practice Address - Street 1:2700 PROSPERITY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4339
Practice Address - Country:US
Practice Address - Phone:703-698-2505
Practice Address - Fax:703-698-2506
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA813571133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered