Provider Demographics
NPI:1194762690
Name:CLELLAND, CAROL O (RD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:O
Last Name:CLELLAND
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 1:118 WASHINGTON STREET
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17105-8700
Practice Address - Country:US
Practice Address - Phone:717-221-6211
Practice Address - Fax:717-221-6266
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001038133N00000X, 133V00000X
PA353735133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1021058820001Medicaid
PA1021058820001Medicaid