Provider Demographics
NPI:1275252306
Name:CUNNINGHAM, NIKKI RENEE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:RENEE
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:NIKKI
Other - Middle Name:RENEE
Other - Last Name:GLISSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LD
Mailing Address - Street 1:538 PEYTON RD
Mailing Address - Street 2:
Mailing Address - City:KEVIL
Mailing Address - State:KY
Mailing Address - Zip Code:42053-9074
Mailing Address - Country:US
Mailing Address - Phone:270-575-8462
Mailing Address - Fax:
Practice Address - Street 1:2501 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3813
Practice Address - Country:US
Practice Address - Phone:270-575-8462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY161871133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered