Provider Demographics
NPI:1740526490
Name:REDAN, MARJORIE (RD, LDN)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:
Last Name:REDAN
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 1:324 WOODLAND WAY
Mailing Address - Street 2:
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-8031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:324 WOODLAND WAY
Practice Address - Street 2:
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-8031
Practice Address - Country:US
Practice Address - Phone:570-836-4669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000412133V00000X, 133VN1004X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic