Provider Demographics
NPI:1417108622
Name:DIMATTEO, MARY ELLEN (RD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:DIMATTEO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 BOBBIN MILL RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1532
Mailing Address - Country:US
Mailing Address - Phone:610-891-6609
Mailing Address - Fax:
Practice Address - Street 1:280 N PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-3527
Practice Address - Country:US
Practice Address - Phone:610-891-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003968133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered