Provider Demographics
NPI:1518385871
Name:ELY, JACQUELINE NICOLE (RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:ELY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WELLNESS WAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-9697
Mailing Address - Country:US
Mailing Address - Phone:724-250-5207
Mailing Address - Fax:724-223-1297
Practice Address - Street 1:240 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-9697
Practice Address - Country:US
Practice Address - Phone:724-250-5207
Practice Address - Fax:724-223-1297
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004384133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered