Provider Demographics
NPI:1215274659
Name:WASKOVICH, LAURIE ELLEN (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELLEN
Last Name:WASKOVICH
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 PUBLIC SQ
Mailing Address - Street 2:SUITE 600
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-1702
Mailing Address - Country:US
Mailing Address - Phone:570-826-1777
Mailing Address - Fax:
Practice Address - Street 1:640 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1631
Practice Address - Country:US
Practice Address - Phone:570-961-5550
Practice Address - Fax:570-961-3844
Is Sole Proprietor?:No
Enumeration Date:2013-01-04
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000965133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027974660003Medicaid
PA1007678420044Medicaid
PA1027974660002Medicaid
PA1027974660004Medicaid
PA1007678420041Medicaid
PA1007678420042Medicaid
PA1007678420040Medicaid