Provider Demographics
NPI:1356447502
Name:MAVIGLIANO, TISH CHAMBRAE (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:TISH
Middle Name:CHAMBRAE
Last Name:MAVIGLIANO
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3718 SPRINGDALE CIR
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-5244
Mailing Address - Country:US
Mailing Address - Phone:270-217-9691
Mailing Address - Fax:
Practice Address - Street 1:6525 U S HIGHWAY 60 W
Practice Address - Street 2:SUITE 100
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001
Practice Address - Country:US
Practice Address - Phone:270-217-9691
Practice Address - Fax:270-575-9515
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1034133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP67458Medicare UPIN
KY3321846Medicare PIN