Provider Demographics
NPI:1992865687
Name:VINCENTI, MARY ANN (RD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:VINCENTI
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:RR#1
Mailing Address - Street 2:BOX 1254A
Mailing Address - City:FORKSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18616-9722
Mailing Address - Country:US
Mailing Address - Phone:570-924-3297
Mailing Address - Fax:
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1909
Practice Address - Country:US
Practice Address - Phone:570-326-8410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000304133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN000304OtherLDN LICENSE