Basic Information
| Provider Information | |||||||||
| NPI: | 1992013296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCANLAN | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | TERESE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LDN, MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24 ORCHARD PL | ||||||||
| Address2: | APT. 205 | ||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304169635 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 116 INTERSTATE PKWY | ||||||||
| Address2: | |||||||||
| City: | BRADFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 167011036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143684143 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2010 | ||||||||
| LastUpdateDate: | 08/17/2011 | ||||||||
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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 | 6588 | OH | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | PA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.