Healthcare Provider Details

I. General information

NPI: 1538440284
Provider Name (Legal Business Name): OLIVIA DANIELLE FRUIT RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 11TH ST
CARROLLTON KY
41008-1435
US

IV. Provider business mailing address

4228 HILLBROOK DR
LOUISVILLE KY
40220-3656
US

V. Phone/Fax

Practice location:
  • Phone: 502-732-3204
  • Fax: 502-732-3213
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2367
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: