Healthcare Provider Details

I. General information

NPI: 1457603359
Provider Name (Legal Business Name): NOURISH ME NUTRITION THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

172 MIDDLETOWN BLVD STE 203
LANGHORNE PA
19047-1871
US

IV. Provider business mailing address

172 MIDDLETOWN BLVD STE 203
LANGHORNE PA
19047-1871
US

V. Phone/Fax

Practice location:
  • Phone: 215-716-1650
  • Fax: 215-600-3354
Mailing address:
  • Phone: 215-726-1650
  • Fax: 215-600-3354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004974
License Number StatePA

VIII. Authorized Official

Name: NATALLIA LASTOVKA
Title or Position: OWNER
Credential: RD, CDCES, LDN
Phone: 215-716-1650