Provider Demographics
NPI:1801190798
Name:BOCCELLA, MAUREEN G (MS, RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:MAUREEN
Middle Name:G
Last Name:BOCCELLA
Suffix:
Gender:F
Credentials:MS, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 RED COAT LN
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1338
Mailing Address - Country:US
Mailing Address - Phone:610-975-9208
Mailing Address - Fax:
Practice Address - Street 1:375 RED COAT LN
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-1338
Practice Address - Country:US
Practice Address - Phone:610-975-9208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-06
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002035133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA12204152OtherCAQH
PA3830821000OtherIBC