Provider Demographics
NPI:1306368253
Name:BROSSMAN, SALLY C (RD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:C
Last Name:BROSSMAN
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 1:409 S 2ND ST STE 2F
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:717-657-7301
Mailing Address - Fax:717-657-7390
Practice Address - Street 1:2015 TECHNOLOGY PKWY
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9414
Practice Address - Country:US
Practice Address - Phone:717-791-2546
Practice Address - Fax:717-221-5299
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004568136A00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103344993Medicaid