Provider Demographics
NPI:1740443993
Name:BUSH-THOMAS, PEGGY JOANN (REGISTERED DIETITIAN)
Entity type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:JOANN
Last Name:BUSH-THOMAS
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9603 WESLAND CIR
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-2043
Mailing Address - Country:US
Mailing Address - Phone:410-922-8124
Mailing Address - Fax:410-922-8124
Practice Address - Street 1:9603 WESLAND CIR
Practice Address - Street 2:
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133-2043
Practice Address - Country:US
Practice Address - Phone:410-922-8124
Practice Address - Fax:410-922-8124
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDOO405133N00000X
MDD00405133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist