Provider Demographics
NPI:1790289718
Name:MARADONNA, CARLIE ELIZABETH (RD, LDN)
Entity Type:Individual
Prefix:MS
First Name:CARLIE
Middle Name:ELIZABETH
Last Name:MARADONNA
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8815 GERMANTOWN AVE STE 22B
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-2722
Mailing Address - Country:US
Mailing Address - Phone:215-753-2060
Mailing Address - Fax:
Practice Address - Street 1:8815 GERMANTOWN AVE STE 22B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2722
Practice Address - Country:US
Practice Address - Phone:215-753-2060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1025759133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered