Basic Information
| Provider Information | |||||||||
| NPI: | 1275186645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURSAW | ||||||||
| FirstName: | KIRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17608 COATBRIDGE PL | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208322318 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 532 BALTIMORE BLVD STE 101 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211576118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6673672778 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2019 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.