MEDICARE: MISS DEANNA MARIE MCCLOUD RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DN007907	PA

General Provider Information

NPI Number	:	1265388417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS DEANNA MARIE MCCLOUD RD

Provider Business Mailing Address
First Line	:	636 MARTIN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1621
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	636 MARTIN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19128-1621
Country	:	US
Telephone Number	:	610-639-1222
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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