Provider Demographics
NPI:1114249455
Name:STEVENS, REGINA A
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:A
Last Name:STEVENS
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 1:500 BOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1916
Mailing Address - Country:US
Mailing Address - Phone:606-678-4761
Mailing Address - Fax:606-676-9671
Practice Address - Street 1:199 ADAMS STREET
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:42539
Practice Address - Country:US
Practice Address - Phone:606-678-4761
Practice Address - Fax:606-676-9671
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1726133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20044012Medicaid
KY20100012Medicaid
KY20027017Medicaid
KY20116018Medicaid
KY20029013Medicaid
KY20109013Medicaid
KY20023016Medicaid
KY20101014Medicaid
KY20901211Medicaid
KY20001012Medicaid
KY20074019Medicaid
KY0300425Medicare PIN
KY20109013Medicaid
KY20100012Medicaid
KY20044012Medicaid
KY0299920Medicare PIN
KY20001012Medicaid
KY20027017Medicaid
KY0300226Medicare PIN
KY20101014Medicaid
KY20901211Medicaid