Provider Demographics
NPI:1760946578
Name:LANDENBURGER, DREW (CNS)
Entity Type:Individual
Prefix:
First Name:DREW
Middle Name:
Last Name:LANDENBURGER
Suffix:
Gender:M
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9686 CARPERS PIKE
Mailing Address - Street 2:
Mailing Address - City:YELLOW SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:26865-9032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9686 CARPERS PIKE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRING
Practice Address - State:WV
Practice Address - Zip Code:26865-9032
Practice Address - Country:US
Practice Address - Phone:301-785-7113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4629133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDDX4629OtherMARYLAND LICENSE #
MDDX4629OtherMARYLAND LICENE