Healthcare Provider Details

I. General information

NPI: 1528979010
Provider Name (Legal Business Name): AMY JO GAWRON I RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3561 WHENGREEN RD
NICHOLSON PA
18446-7695
US

IV. Provider business mailing address

3561 WHENGREEN RD
NICHOLSON PA
18446-7695
US

V. Phone/Fax

Practice location:
  • Phone: 570-698-5647
  • Fax: 570-698-7742
Mailing address:
  • Phone: 570-698-5647
  • Fax: 570-698-7742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001127
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: