Provider Demographics
NPI:1417977828
Name:MAHER, ANN (LRD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:MAHER
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:
Other - Last Name:MAHER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD, LN
Mailing Address - Street 1:PO BOX 860
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625-0860
Mailing Address - Country:US
Mailing Address - Phone:605-964-8000
Mailing Address - Fax:605-964-1118
Practice Address - Street 1:315 MAIN ST.
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625-0860
Practice Address - Country:US
Practice Address - Phone:605-964-8000
Practice Address - Fax:605-964-1118
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0325133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD711401Medicare PIN