Healthcare Provider Details

I. General information

NPI: 1508405994
Provider Name (Legal Business Name): MARYAM NIKANTABAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 GRAISBURY AVE
HADDONFIELD NJ
08033-3021
US

IV. Provider business mailing address

435 BEECH AVE
HERSHEY PA
17033-1610
US

V. Phone/Fax

Practice location:
  • Phone: 570-985-0955
  • Fax:
Mailing address:
  • Phone: 570-985-0955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License NumberDN006783
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: