Provider Demographics
NPI:1851124622
Name:SAMPLE - ADAMS, SERWA CARRIE - LAKE (RD)
Entity type:Individual
Prefix:
First Name:SERWA
Middle Name:CARRIE - LAKE
Last Name:SAMPLE - ADAMS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SERWA
Other - Middle Name:CARRIE
Other - Last Name:LAKE - SAMPLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:3801 CONSHOHOCKEN AVE APT 710
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-5544
Mailing Address - Country:US
Mailing Address - Phone:518-528-8977
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:518-528-8977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007797133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered