Provider Demographics
NPI:1376781617
Name:MATHEWS, COLLEEN (RD)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:MATHEWS
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 1:1430 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:OH
Mailing Address - Zip Code:45215-2116
Mailing Address - Country:US
Mailing Address - Phone:513-218-3815
Mailing Address - Fax:
Practice Address - Street 1:1430 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:OH
Practice Address - Zip Code:45215-2116
Practice Address - Country:US
Practice Address - Phone:513-218-3815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-24
Last Update Date:2009-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6075133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric