Provider Demographics
NPI:1790391118
Name:RIDDLE, ELIZABETH MARIE (RD, LD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:RIDDLE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 NORTON HEALTHCARE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2832
Mailing Address - Country:US
Mailing Address - Phone:502-394-6415
Mailing Address - Fax:502-244-0684
Practice Address - Street 1:4955 NORTON HEALTHCARE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2832
Practice Address - Country:US
Practice Address - Phone:502-394-6415
Practice Address - Fax:502-244-0684
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003207A133V00000X, 133VN1301X
KY166845133VN1301X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1301XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Oncology