Healthcare Provider Details

I. General information

NPI: 1043468184
Provider Name (Legal Business Name): ESSENTIAL NUTRITION FOR WELLNESS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1941 HAMILTON ST STE 102
ALLENTOWN PA
18104-6470
US

IV. Provider business mailing address

2672 TOWNSHIP LINE RD
OREFIELD PA
18069-2845
US

V. Phone/Fax

Practice location:
  • Phone: 610-703-4502
  • Fax:
Mailing address:
  • Phone: 610-703-4502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDN001564
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDN001564
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001564
License Number StatePA

VIII. Authorized Official

Name: MS. SUZANNE YOST
Title or Position: MEMBER
Credential: RD, LDN
Phone: 610-703-4502