Provider Demographics
NPI:1912725755
Name:STARK, JUANITA ELIZABETH (RDN, LDN)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:ELIZABETH
Last Name:STARK
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 ROLLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:SELINSGROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17870-9492
Mailing Address - Country:US
Mailing Address - Phone:570-847-1111
Mailing Address - Fax:
Practice Address - Street 1:8 W SNYDER ST STE 2
Practice Address - Street 2:
Practice Address - City:SELINSGROVE
Practice Address - State:PA
Practice Address - Zip Code:17870-1504
Practice Address - Country:US
Practice Address - Phone:570-847-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003275133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered