Basic Information
| Provider Information | |||||||||
| NPI: | 1730528423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARRIS | ||||||||
| FirstName: | LYNNE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DIETICIAN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARRIS | ||||||||
| OtherFirstName: | LYNNE | ||||||||
| OtherMiddleName: | DOLAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 827658 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191827658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704204951 | ||||||||
| FaxNumber: | 5704763754 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 PLAZA CT | ||||||||
| Address2: | STE D | ||||||||
| City: | EAST STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183018262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704262330 | ||||||||
| FaxNumber: | 5704262331 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
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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 | DN000503 | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.