Provider Demographics
NPI:1801401468
Name:DOUGHTY, ANDREA (RD, CDCES)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:DOUGHTY
Suffix:
Gender:F
Credentials:RD, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 PARKVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2362
Mailing Address - Country:US
Mailing Address - Phone:859-250-8928
Mailing Address - Fax:
Practice Address - Street 1:207 TRADITIONS BLVD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7957
Practice Address - Country:US
Practice Address - Phone:270-901-3412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY168623133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered