Provider Demographics
NPI:1992195887
Name:BEMBENEK, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BEMBENEK
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 1:8500 EXECUTIVE PARK AVE STE 300A
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-2228
Mailing Address - Country:US
Mailing Address - Phone:703-698-7117
Mailing Address - Fax:
Practice Address - Street 1:8500 EXECUTIVE PARK AVE STE 300A
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-2228
Practice Address - Country:US
Practice Address - Phone:703-698-7117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-29
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3614133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist