MEDICARE: PAULA L CLINTON DTR

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	136A00000X	Registered Dietetic Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	105846	OTHER	NJ	AMERIGROUP PROVIDER #

General Provider Information

NPI Number	:	1609945393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAULA L CLINTON DTR

Provider Business Mailing Address
First Line	:	111 BERMUDA DR
Second Line	:
City	:	BRANCHBURG
State	:	NJ
Zip	:	08853-4286
Country	:	US
Telephone Number	:	908-336-0372
Fax Number	:

Provider Business Practice Location Address
First Line	:	701 NEWARK AVE
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07208-3550
Country	:	US
Telephone Number	:	908-346-0269
Fax Number	:

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/08/2007

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