Provider Demographics
NPI:1669135786
Name:DWYER, DANIELLE M (RD, CNSC)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:DWYER
Suffix:
Gender:F
Credentials:RD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 W BROAD ST UNIT 421
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-4942
Mailing Address - Country:US
Mailing Address - Phone:815-354-0402
Mailing Address - Fax:
Practice Address - Street 1:1401 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4789
Practice Address - Country:US
Practice Address - Phone:804-483-5135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86115449133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered