Provider Demographics
NPI:1265125421
Name:MCCLENDON, MARY BETH (MPH, RD,LD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:MCCLENDON
Suffix:
Gender:F
Credentials:MPH, RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 IVA DEL CT
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE PARK
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1561
Mailing Address - Country:US
Mailing Address - Phone:859-757-8496
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3403
Practice Address - Country:US
Practice Address - Phone:859-301-4094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-01
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY718887133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered