Provider Demographics
NPI:1619367448
Name:MOORE, HEATHER MITCHELL (MS, CNS, LDN, RDCS)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:MITCHELL
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, CNS, LDN, RDCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8909 VICTORY LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3647
Mailing Address - Country:US
Mailing Address - Phone:301-651-0033
Mailing Address - Fax:
Practice Address - Street 1:8909 VICTORY LN
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3647
Practice Address - Country:US
Practice Address - Phone:301-651-0033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3723133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist