Healthcare Provider Details

I. General information

NPI: 1548296072
Provider Name (Legal Business Name): ELLEN KATHLEEN SOURS R.D.,L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4689 FULTON DR NW
CANTON OH
44718-2379
US

IV. Provider business mailing address

4685 FULTON DR NW
CANTON OH
44718-2379
US

V. Phone/Fax

Practice location:
  • Phone: 330-649-9400
  • Fax: 330-649-8059
Mailing address:
  • Phone: 330-649-9300
  • Fax: 330-649-8058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1569
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: