Provider Demographics
NPI:1992105548
Name:FULL STRIDE WELLNESS
Entity type:Organization
Organization Name:FULL STRIDE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:ATC, LAT
Authorized Official - Phone:410-833-0503
Mailing Address - Street 1:100 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-1229
Mailing Address - Country:US
Mailing Address - Phone:410-833-0503
Mailing Address - Fax:
Practice Address - Street 1:100 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1229
Practice Address - Country:US
Practice Address - Phone:410-833-0503
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3643133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty