Provider Demographics
NPI:1952456600
Name:KETHAMUKKALA, LAVANYA (RD)
Entity Type:Individual
Prefix:MRS
First Name:LAVANYA
Middle Name:
Last Name:KETHAMUKKALA
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 1:3508 LILY ORCHARD WAY
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-9601
Mailing Address - Country:US
Mailing Address - Phone:919-342-6179
Mailing Address - Fax:919-342-5871
Practice Address - Street 1:3508 LILY ORCHARD WAY
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27539-9601
Practice Address - Country:US
Practice Address - Phone:919-342-6179
Practice Address - Fax:919-342-5871
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004157133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered