Healthcare Provider Details

I. General information

NPI: 1902476849
Provider Name (Legal Business Name): BETHANY MIORELLI RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 E BROAD ST
SOUDERTON PA
18964-1214
US

IV. Provider business mailing address

406 E BROAD ST
SOUDERTON PA
18964-1214
US

V. Phone/Fax

Practice location:
  • Phone: 215-896-4875
  • Fax:
Mailing address:
  • Phone: 215-896-4875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN007139
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: