Provider Demographics
NPI:1447266358
Name:MACKULIN, GEORGANNE (RD)
Entity type:Individual
Prefix:MRS
First Name:GEORGANNE
Middle Name:
Last Name:MACKULIN
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 1:141 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-2444
Mailing Address - Country:US
Mailing Address - Phone:412-469-5797
Mailing Address - Fax:412-469-7725
Practice Address - Street 1:565 COAL VALLEY RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON HILLS
Practice Address - State:PA
Practice Address - Zip Code:15025-3703
Practice Address - Country:US
Practice Address - Phone:412-469-5797
Practice Address - Fax:412-469-7725
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered