Provider Demographics
NPI:1386941730
Name:FULLER, MARY TERESA (RD,LD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:TERESA
Last Name:FULLER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 BURTONWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22307-2024
Mailing Address - Country:US
Mailing Address - Phone:703-300-3871
Mailing Address - Fax:
Practice Address - Street 1:8218 WISCONSIN AVENUE
Practice Address - Street 2:SUITE 305
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-652-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD02105133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered