Provider Demographics
NPI:1124197132
Name:KLEM, MARY BYRNE (MS RD LDN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BYRNE
Last Name:KLEM
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 CHAPMAN LAKE RD
Mailing Address - Street 2:
Mailing Address - City:JERMYN
Mailing Address - State:PA
Mailing Address - Zip Code:18433-3145
Mailing Address - Country:US
Mailing Address - Phone:570-254-6495
Mailing Address - Fax:570-254-6495
Practice Address - Street 1:1134 CHAPMAN LAKE RD
Practice Address - Street 2:
Practice Address - City:JERMYN
Practice Address - State:PA
Practice Address - Zip Code:18433-3145
Practice Address - Country:US
Practice Address - Phone:570-254-6495
Practice Address - Fax:570-254-6495
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000794133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA055485Medicare ID - Type Unspecified