Provider Demographics
NPI:1679863971
Name:MATHAROO, SARAH L (REGISTERED DIETICIAN)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:L
Last Name:MATHAROO
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:L
Other - Last Name:GAJEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 2917
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2917
Mailing Address - Country:US
Mailing Address - Phone:606-218-4811
Mailing Address - Fax:
Practice Address - Street 1:1098 S MAYO TRL
Practice Address - Street 2:SUITE 303
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1546
Practice Address - Country:US
Practice Address - Phone:606-218-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1011500133VN1004X
KY2432133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid
VA004909976Medicaid