Provider Demographics
NPI:1609830728
Name:LASALLE, PATRICIA L (RD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:LASALLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:L
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1243 S CEDAR CREST BLVD
Practice Address - Street 2:STE 2200
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6268
Practice Address - Country:US
Practice Address - Phone:610-402-5000
Practice Address - Fax:610-402-8539
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP00216052OtherRAILROAD MEDICARE
PA078857R8GMedicare ID - Type Unspecified