Provider Demographics
NPI:1164838694
Name:CAMPANELLA, MARISSA (RD, LDN, CEDRD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:CAMPANELLA
Suffix:
Gender:F
Credentials:RD, LDN, CEDRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 PITTSTON AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2964
Mailing Address - Country:US
Mailing Address - Phone:570-604-2733
Mailing Address - Fax:
Practice Address - Street 1:3218 PITTSTON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505
Practice Address - Country:US
Practice Address - Phone:570-731-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-04
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA86026263133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered