Basic Information
| Provider Information | |||||||||
| NPI: | 1710121611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDA | ||||||||
| FirstName: | TAMARA | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | R.D., L.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 214 CARPENTER HILL RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH ABINGTON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184112915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705866196 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 435 SCRANTON CARBONDALE HWY | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | SCRANTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 185081115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703434334 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 04/23/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DN000932 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.