Provider Demographics
NPI:1487004834
Name:PAVESI, BETHANY (RD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:PAVESI
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 1:5800 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-1737
Mailing Address - Country:US
Mailing Address - Phone:215-487-4341
Mailing Address - Fax:215-487-4331
Practice Address - Street 1:5800 RIDGE AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-1737
Practice Address - Country:US
Practice Address - Phone:215-487-4341
Practice Address - Fax:215-487-4331
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005571133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered