Provider Demographics
NPI:1245402544
Name:TRIPP, ROBERTA (RD)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:TRIPP
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:JERYL
Other - Last Name:ROSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:118 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S FRONT STREET
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-1020
Practice Address - Country:US
Practice Address - Phone:717-782-5283
Practice Address - Fax:717-782-5192
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000026133V00000X
PA513983133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021062260001Medicaid
PA9068015OtherCIGNA