Healthcare Provider Details

I. General information

NPI: 1174973440
Provider Name (Legal Business Name): DORIE ELLEN OBERTELLO RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E ERIE AVE DEPARTMENT OF CLINICAL NUTRITION
PHILADELPHIA PA
19134-1011
US

IV. Provider business mailing address

160 E ERIE AVE DEPARTMENT OF CLINICAL NUTRITION
PHILADELPHIA PA
19134-1011
US

V. Phone/Fax

Practice location:
  • Phone: 215-427-3823
  • Fax:
Mailing address:
  • Phone: 215-427-3823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDN005831
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: