Provider Demographics
NPI:1811083884
Name:SISTRUNK, MARY (RD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SISTRUNK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 OLD WASHINGTON RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-3233
Mailing Address - Country:US
Mailing Address - Phone:301-609-5200
Mailing Address - Fax:301-609-5220
Practice Address - Street 1:3510 OLD WASHINGTON RD
Practice Address - Street 2:SUITE #100
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-3233
Practice Address - Country:US
Practice Address - Phone:301-609-5200
Practice Address - Fax:301-609-5220
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDKP70H348Medicare PIN