Provider Demographics
NPI:1558689109
Name:BASILA-KING, GLADYS M (RD)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:M
Last Name:BASILA-KING
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 1:5 DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:SPRING BROOK TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18444-6232
Mailing Address - Country:US
Mailing Address - Phone:570-877-8620
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004153133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered