Provider Demographics
NPI:1629708284
Name:REID, MARKELL ROSE
Entity Type:Individual
Prefix:
First Name:MARKELL
Middle Name:ROSE
Last Name:REID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4418 FLEMING ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-4809
Mailing Address - Country:US
Mailing Address - Phone:585-775-7351
Mailing Address - Fax:
Practice Address - Street 1:4418 FLEMING ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-4809
Practice Address - Country:US
Practice Address - Phone:585-775-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86118017133V00000X
PA86118017133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered