Provider Demographics
NPI:1376036061
Name:VATANASOMBAT, AINSLEY (RD)
Entity Type:Individual
Prefix:
First Name:AINSLEY
Middle Name:
Last Name:VATANASOMBAT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:AINSLEY
Other - Middle Name:
Other - Last Name:LYONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4115 WEST LUDWIG CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68528
Mailing Address - Country:US
Mailing Address - Phone:515-991-3176
Mailing Address - Fax:
Practice Address - Street 1:4101 WOOLWORTH AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-1850
Practice Address - Country:US
Practice Address - Phone:402-346-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1239133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered