Provider Demographics
NPI:1770548471
Name:CUNNINGHAM, SHELLIE RYAN (RD)
Entity type:Individual
Prefix:MRS
First Name:SHELLIE
Middle Name:RYAN
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SHELLIE
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:510 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OWENTON
Mailing Address - State:KY
Mailing Address - Zip Code:40359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1005 HIGHWAY 22 E
Practice Address - Street 2:OWEN COUNTY HEALTH CENTER
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359-9041
Practice Address - Country:US
Practice Address - Phone:502-732-6641
Practice Address - Fax:502-732-8681
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1563133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0050609Medicare ID - Type UnspecifiedOCHC
KY0280707Medicare ID - Type UnspecifiedGCHC
KY0280608Medicare ID - Type UnspecifiedPCHC
KY0280808Medicare ID - Type UnspecifiedCCHC