Provider Demographics
NPI:1265594816
Name:NURRUDDIN, AYESHA (MS,RD,LD)
Entity type:Individual
Prefix:
First Name:AYESHA
Middle Name:
Last Name:NURRUDDIN
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W MARKET ST # 148
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-7002
Mailing Address - Country:US
Mailing Address - Phone:330-873-1918
Mailing Address - Fax:330-864-2580
Practice Address - Street 1:991 VALDES AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2633
Practice Address - Country:US
Practice Address - Phone:330-873-1918
Practice Address - Fax:330-864-2580
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD2041133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP58130Medicare UPIN
OHMT01142Medicare PIN