Provider Demographics
NPI:1811928591
Name:MULL, STEPHANIE (MS, RD, CSSD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MULL
Suffix:
Gender:F
Credentials:MS, RD, CSSD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:DACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:44983 KNOLL SQ
Mailing Address - Street 2:ENTERPRISE HALL, ROOM B25
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-2692
Mailing Address - Country:US
Mailing Address - Phone:571-553-0539
Mailing Address - Fax:
Practice Address - Street 1:44983 KNOLL SQ
Practice Address - Street 2:ENTERPRISE HALL, ROOM B25
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-2692
Practice Address - Country:US
Practice Address - Phone:571-553-0539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA875320133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009698N42Medicare ID - Type Unspecified