Provider Demographics
NPI:1104871672
Name:ZELEZNOCK, GRACE (RD)
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:
Last Name:ZELEZNOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4309
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:175 SOUTH WILKES-BARRE BLVD.
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-3838
Practice Address - Country:US
Practice Address - Phone:570-829-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000063133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA070972Medicare ID - Type Unspecified
P92476Medicare UPIN