Provider Demographics
NPI:1407884539
Name:FABERT-KINNEER, THERESA M (LDN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:FABERT-KINNEER
Suffix:
Gender:F
Credentials:LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 HOSPITAL ROAD
Mailing Address - Street 2:PO BOX 788
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-0788
Mailing Address - Country:US
Mailing Address - Phone:724-357-7009
Mailing Address - Fax:724-357-7414
Practice Address - Street 1:835 HOSPITAL ROAD
Practice Address - Street 2:DIETITIAN
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-0788
Practice Address - Country:US
Practice Address - Phone:724-357-7089
Practice Address - Fax:724-357-8046
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN 001059133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058792GU9Medicare ID - Type Unspecified