Provider Demographics
NPI:1588722490
Name:LEWIS, CHERYL DISCH (MSRDLDN)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:DISCH
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MSRDLDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 E VAUGHN ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-4817
Mailing Address - Country:US
Mailing Address - Phone:570-283-1182
Mailing Address - Fax:
Practice Address - Street 1:1130 HIGHWAY 315 STE B
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6952
Practice Address - Country:US
Practice Address - Phone:570-823-8896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001033133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA056154OtherMEDICARE PROVIDER #
PA710093OtherREGISTERED DIETITIAN
PADN001033OtherLDN LICENSE