Provider Demographics
NPI:1639828171
Name:SANTELLA, MADISON (RD, LD)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:SANTELLA
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 LEECHBURG RD
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-3096
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:710 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:MC KEES ROCKS
Practice Address - State:PA
Practice Address - Zip Code:15136-3808
Practice Address - Country:US
Practice Address - Phone:412-771-6462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007193133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86083414OtherCDR REGISTRATION ID