Provider Demographics
NPI:1992013296
Name:SCANLAN, KRISTINE TERESE (RD, LDN, MS)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:TERESE
Last Name:SCANLAN
Suffix:
Gender:F
Credentials:RD, LDN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 ORCHARD PL
Mailing Address - Street 2:APT. 205
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-1072
Mailing Address - Country:US
Mailing Address - Phone:330-416-9635
Mailing Address - Fax:
Practice Address - Street 1:116 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-1036
Practice Address - Country:US
Practice Address - Phone:814-368-4143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6588133V00000X
PA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered