Provider Demographics
NPI:1801258298
Name:BRAGG, CARLY ELIZABETH (RDN)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:BRAGG
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1833
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20146-1833
Mailing Address - Country:US
Mailing Address - Phone:703-552-2722
Mailing Address - Fax:703-564-8567
Practice Address - Street 1:5999 STEVENSON AVE STE 405
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-3302
Practice Address - Country:US
Practice Address - Phone:703-552-2722
Practice Address - Fax:703-564-8567
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist