Provider Demographics
NPI:1376693549
Name:THEODORE, JOANN (RD)
Entity Type:Individual
Prefix:MS
First Name:JOANN
Middle Name:
Last Name:THEODORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 PIPESTEM PLACE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854
Mailing Address - Country:US
Mailing Address - Phone:301-704-2179
Mailing Address - Fax:
Practice Address - Street 1:12105 DARNESTOWN RD
Practice Address - Street 2:SUITE L8
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-2217
Practice Address - Country:US
Practice Address - Phone:301-869-0006
Practice Address - Fax:301-869-0201
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02111133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered