Provider Demographics
NPI:1255491379
Name:GRIFFIN, MARY TIM (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:TIM
Last Name:GRIFFIN
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 1:1501 BRECKENRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1054
Mailing Address - Country:US
Mailing Address - Phone:270-686-7747
Mailing Address - Fax:
Practice Address - Street 1:1501 BRECKENRIDGE ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1054
Practice Address - Country:US
Practice Address - Phone:270-686-7747
Practice Address - Fax:270-926-9862
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0282718Medicare PIN
KY0944711Medicare PIN
KY0282321Medicare PIN
KY0282818Medicare PIN
KY0282421Medicare PIN
0049229Medicare PIN
KY0282620Medicare PIN
KY0282521Medicare PIN