Provider Demographics
NPI:1588825335
Name:CHEATHAM, MARY A (RD)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:CHEATHAM
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 1:3720 RAIKES HILL RD
Mailing Address - Street 2:
Mailing Address - City:ELK HORN
Mailing Address - State:KY
Mailing Address - Zip Code:42733-9717
Mailing Address - Country:US
Mailing Address - Phone:270-789-0625
Mailing Address - Fax:
Practice Address - Street 1:3720 RAIKES HILL RD
Practice Address - Street 2:
Practice Address - City:ELK HORN
Practice Address - State:KY
Practice Address - Zip Code:42733-9717
Practice Address - Country:US
Practice Address - Phone:270-789-0625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2009-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1119133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20023016Medicaid
KY20074019Medicaid
KY20001012Medicaid
KY20901211Medicaid
KY20044012Medicaid
KY20029013Medicaid
KY20027017Medicaid
KY20104014Medicaid
KY20109013Medicaid
KY20116018Medicaid
KY20100012Medicaid
KY0300017Medicare PIN
KY20029013Medicaid
KY0300317Medicare PIN
KY0300119Medicare PIN
KY20027017Medicaid
KY0300419Medicare PIN
KY20901211Medicaid
KY0300717Medicare PIN
KY0299917Medicare PIN
KY0300219Medicare PIN