Provider Demographics
NPI:1790537801
Name:OLDHAM, AVERY (RD, LD)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:OLDHAM
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 1:414 HEDRICK ST
Mailing Address - Street 2:
Mailing Address - City:BUCKNER
Mailing Address - State:MO
Mailing Address - Zip Code:64016-9566
Mailing Address - Country:US
Mailing Address - Phone:816-225-0725
Mailing Address - Fax:
Practice Address - Street 1:414 HEDRICK ST
Practice Address - Street 2:
Practice Address - City:BUCKNER
Practice Address - State:MO
Practice Address - Zip Code:64016-9566
Practice Address - Country:US
Practice Address - Phone:816-225-0725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO86083524133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered