Basic Information
Provider Information | |||||||||
NPI: | 1104260793 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STAYMAN | ||||||||
FirstName: | BRANDY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD, LDN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BAXTER | ||||||||
OtherFirstName: | BRANDY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RD,LPN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8110 MAPLE LAWN BLVD STE 235 | ||||||||
Address2: |   | ||||||||
City: | FULTON | ||||||||
State: | MD | ||||||||
PostalCode: | 207592694 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3013408339 | ||||||||
FaxNumber: | 3013409027 | ||||||||
Practice Location | |||||||||
Address1: | 1165 IMPERIAL DR STE 300 | ||||||||
Address2: |   | ||||||||
City: | HAGERSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 217406556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3016659098 | ||||||||
FaxNumber: | 3016659096 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2013 | ||||||||
LastUpdateDate: | 05/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DX3004 | MD | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | DX3004 | 01 | MD | STATE BOARD OF DIETETIC PRACTICE | OTHER |