Provider Demographics
NPI:1477064863
Name:NOURISHING NUTRITIONALS LLC
Entity type:Organization
Organization Name:NOURISHING NUTRITIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:W
Authorized Official - Last Name:GATHOGO
Authorized Official - Suffix:
Authorized Official - Credentials:RD LDN
Authorized Official - Phone:443-776-8429
Mailing Address - Street 1:1224 CEDARCROFT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-1921
Mailing Address - Country:US
Mailing Address - Phone:443-776-8429
Mailing Address - Fax:866-311-5636
Practice Address - Street 1:1224 CEDARCROFT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-1921
Practice Address - Country:US
Practice Address - Phone:443-776-8429
Practice Address - Fax:866-311-5636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-12
Last Update Date:2018-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX2478133V00000X
MDDX22478133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDW18299354OtherDEPARTMENT ID