Provider Demographics
NPI:1225142706
Name:TUCKER, KATHRYN LOUISE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LOUISE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 HOSPITAL ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:KY
Mailing Address - Zip Code:42633-2416
Mailing Address - Country:US
Mailing Address - Phone:606-340-3216
Mailing Address - Fax:606-340-3220
Practice Address - Street 1:166 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-2416
Practice Address - Country:US
Practice Address - Phone:606-340-3216
Practice Address - Fax:606-340-3220
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYQ08885Medicare UPIN
KY3334424Medicare ID - Type UnspecifiedMEDICARE NUMBER