Provider Demographics
NPI:1891223426
Name:BROCKETT, CHRISTINA (MS, CNS, LDN)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:BROCKETT
Suffix:
Gender:F
Credentials:MS, CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5718 NOTTINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:ADAMSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21710-9473
Mailing Address - Country:US
Mailing Address - Phone:301-874-2957
Mailing Address - Fax:
Practice Address - Street 1:5718 NOTTINGHAM PL
Practice Address - Street 2:
Practice Address - City:ADAMSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21710-9473
Practice Address - Country:US
Practice Address - Phone:301-874-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4209133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist