Provider Demographics
NPI:1861086985
Name:WAZOBIAN HOLDINGS LLC
Entity type:Organization
Organization Name:WAZOBIAN HOLDINGS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:
Authorized Official - First Name:ADANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:IBE
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:240-751-0591
Mailing Address - Street 1:2601 PARK CENTER DR APT C703
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1477
Mailing Address - Country:US
Mailing Address - Phone:240-751-0691
Mailing Address - Fax:
Practice Address - Street 1:9244 E HAMPTON DR STE 204
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-3830
Practice Address - Country:US
Practice Address - Phone:240-473-2955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-01
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Single Specialty
No133VN1101XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, GerontologicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCDI100001161OtherDC DIETETICS LICENSE NUMBER
1086540OtherCDR REGISTRATION NUMBER
MDDX3953OtherMARYLAND DIETETICS LICENSE NUMBER