Healthcare Provider Details

I. General information

NPI: 1275728578
Provider Name (Legal Business Name): DEBORAH SUSAN DEPASTINA RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2007
Last Update Date: 09/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDCOM
APO SEOUL
96205
KP

IV. Provider business mailing address

207 LINCOLN AVE
HOLLIDAYSBURG PA
16648-1311
US

V. Phone/Fax

Practice location:
  • Phone: 814-327-6252
  • Fax:
Mailing address:
  • Phone: 814-327-6252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT03881
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: