Provider Demographics
NPI:1407188428
Name:MACK, TAMELA JEANINE (RD)
Entity Type:Individual
Prefix:
First Name:TAMELA
Middle Name:JEANINE
Last Name:MACK
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 1:417 PEABODY STREET NORTHEAST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20011-1645
Mailing Address - Country:US
Mailing Address - Phone:202-529-0582
Mailing Address - Fax:202-529-0220
Practice Address - Street 1:417 PEABODY STREET NORTHEAST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-1645
Practice Address - Country:US
Practice Address - Phone:202-529-0582
Practice Address - Fax:202-529-0220
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-01
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND3748133V00000X
MDDO2317133V00000X
DCDI682133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered