Provider Demographics
NPI:1588607022
Name:RICHARDS, MARYELLEN (RD, LDN)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:KANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WASHINGTON ST
Practice Address - Street 2:LEARNING INSTITUTE
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1675
Practice Address - Country:US
Practice Address - Phone:717-221-6258
Practice Address - Fax:717-221-6266
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA436344133V00000X
PADN001201133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102106360Medicaid
PA057905Medicare PIN