Provider Demographics
NPI:1053597229
Name:MACKLIN, AMY LYNN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LYNN
Last Name:MACKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 TRAILSIDE CT
Mailing Address - Street 2:
Mailing Address - City:CORAOPOLIS
Mailing Address - State:PA
Mailing Address - Zip Code:15108-9169
Mailing Address - Country:US
Mailing Address - Phone:412-916-4890
Mailing Address - Fax:
Practice Address - Street 1:114 TRAILSIDE CT
Practice Address - Street 2:
Practice Address - City:CORAOPOLIS
Practice Address - State:PA
Practice Address - Zip Code:15108-9169
Practice Address - Country:US
Practice Address - Phone:412-916-4890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002704133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered