MEDICARE: MS. MARY ELIZABETH MCCANN RD,LDN

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
2	133V00000X	Registered Dietitian	886730	NJ

General Provider Information

NPI Number	:	1417990474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY ELIZABETH MCCANN RD,LDN

Provider Business Mailing Address
First Line	:	22 CENTER ST APT E
Second Line	:
City	:	FORTY FORT
State	:	PA
Zip	:	18704-5062
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 CENTER ST APT E
Second Line	:
City	:	FORTY FORT
State	:	PA
Zip	:	18704-5062
Country	:	US
Telephone Number	:	570-242-6162
Fax Number	:

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	10/01/2014

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