Healthcare Provider Details

I. General information

NPI: 1689766156
Provider Name (Legal Business Name): MARILYNN C KSIAZEK MS RD CDE LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 CLEVELAND ST
OLYPHANT PA
18447-1661
US

IV. Provider business mailing address

302 CLEVELAND ST
OLYPHANT PA
18447-1661
US

V. Phone/Fax

Practice location:
  • Phone: 570-489-0303
  • Fax: 570-489-0303
Mailing address:
  • Phone: 570-489-0303
  • Fax: 570-489-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN000291
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: