Provider Demographics
NPI:1306234836
Name:LUNDBERG, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 W DIAMOND AVE
Mailing Address - Street 2:SUITE #110
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20878-1415
Mailing Address - Country:US
Mailing Address - Phone:301-515-2902
Mailing Address - Fax:
Practice Address - Street 1:806 W DIAMOND AVE
Practice Address - Street 2:SUITE #110
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20878-1415
Practice Address - Country:US
Practice Address - Phone:301-515-2902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005628363A00000X
PAOA003388363A00000X
PAMA057147363A00000X
VA0110-004791363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant