Healthcare Provider Details

I. General information

NPI: 1518501055
Provider Name (Legal Business Name): KEYSTONE NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 OLD OAKS RD
BRYN MAWR PA
19010-1024
US

IV. Provider business mailing address

512 W LANCASTER AVE
WAYNE PA
19087-3122
US

V. Phone/Fax

Practice location:
  • Phone: 610-324-9398
  • Fax:
Mailing address:
  • Phone: 610-525-1422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MS. MELISSA WILSON TWEDT
Title or Position: CLINICAL NUTRITIONIST
Credential: MS, CNS, LDN
Phone: 610-525-1422