Healthcare Provider Details

I. General information

NPI: 1861145047
Provider Name (Legal Business Name): OLIVIA SUTTON RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 FRANKLIN ST STE 180
JOHNSTOWN PA
15905-4341
US

IV. Provider business mailing address

124 GILMARTIN DR
LORETTO PA
15940-7303
US

V. Phone/Fax

Practice location:
  • Phone: 814-534-6800
  • Fax:
Mailing address:
  • Phone: 814-515-3510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004398
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: