Healthcare Provider Details

I. General information

NPI: 1881998037
Provider Name (Legal Business Name): SHARYL FIDOTEN RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2011
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 HICKORY RD SUITE 240
PLYMOUTH MEETING PA
19462-1047
US

IV. Provider business mailing address

2250 HICKORY RD SUITE 240
PLYMOUTH MEETING PA
19462-1047
US

V. Phone/Fax

Practice location:
  • Phone: 856-795-0016
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN004052
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT04459
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164002890
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: