Provider Demographics
NPI:1386014819
Name:PHULSUKSOMBATI, MICHELE (MS, MED,RD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:PHULSUKSOMBATI
Suffix:
Gender:F
Credentials:MS, MED,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 BLUE HERON DR
Mailing Address - Street 2:2D
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-9358
Mailing Address - Country:US
Mailing Address - Phone:301-788-5392
Mailing Address - Fax:
Practice Address - Street 1:8200 BLUE HERON DR
Practice Address - Street 2:2D
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-9358
Practice Address - Country:US
Practice Address - Phone:301-788-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3822133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered