Provider Demographics
NPI:1962814418
Name:RIEDEL, PAMELA JACOBSON (RD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JACOBSON
Last Name:RIEDEL
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 1:111 ESSEX RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-1330
Mailing Address - Country:US
Mailing Address - Phone:561-516-0728
Mailing Address - Fax:
Practice Address - Street 1:111 ESSEX RD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33024-1330
Practice Address - Country:US
Practice Address - Phone:561-516-0728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 6849133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered