Healthcare Provider Details

I. General information

NPI: 1639138738
Provider Name (Legal Business Name): FAITH C. MCMAHON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

IV. Provider business mailing address

1 GUTHRIE SQ
SAYRE PA
18840-1625
US

V. Phone/Fax

Practice location:
  • Phone: 570-888-5858
  • Fax:
Mailing address:
  • Phone: 570-888-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDN000669
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number005377-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN000669
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005377-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: