Provider Demographics
NPI:1336409135
Name:FULDA, CONSTANCE L (RD)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:L
Last Name:FULDA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
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Mailing Address - Street 1:15210 DINO DR UNIT 825
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-7536
Mailing Address - Country:US
Mailing Address - Phone:301-246-6255
Mailing Address - Fax:301-936-1994
Practice Address - Street 1:13221 SCHUBERT PL
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-6865
Practice Address - Country:US
Practice Address - Phone:301-246-6255
Practice Address - Fax:301-936-1994
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2022-08-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDDX3663133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3D2787061Medicare PIN