Provider Demographics
NPI:1952058810
Name:FULP-EICKSTAEDT, REBECCA (CNS, LDN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:FULP-EICKSTAEDT
Suffix:
Gender:F
Credentials:CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8303 ARLINGTON BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8303 ARLINGTON BLVD STE 110
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2903
Practice Address - Country:US
Practice Address - Phone:571-257-3378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-09
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5414133N00000X
VA18336133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist