Provider Demographics
NPI:1780646448
Name:MERVIS, CHARLA D (RD)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:D
Last Name:MERVIS
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 1:210 LOCUST ST
Mailing Address - Street 2:APT 26D
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3934
Mailing Address - Country:US
Mailing Address - Phone:215-923-1360
Mailing Address - Fax:
Practice Address - Street 1:1201 LANGHORNE NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:LANGHORNE
Practice Address - State:PA
Practice Address - Zip Code:19047-1201
Practice Address - Country:US
Practice Address - Phone:215-710-2058
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003198133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA089588R8GMedicare ID - Type Unspecified