Healthcare Provider Details

I. General information

NPI: 1427629427
Provider Name (Legal Business Name): IMAN SHALASH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3167 CUSTER DR
LEXINGTON KY
40517-4018
US

IV. Provider business mailing address

3167 CUSTER DR
LEXINGTON KY
40517-4018
US

V. Phone/Fax

Practice location:
  • Phone: 859-388-9152
  • Fax: 859-208-2234
Mailing address:
  • Phone: 859-388-9152
  • Fax: 859-208-2234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: