Healthcare Provider Details

I. General information

NPI: 1750206926
Provider Name (Legal Business Name): MARY SHANNON BURKHOLDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 HARRODSBURG RD
LEXINGTON KY
40504-3758
US

IV. Provider business mailing address

1060 CHASEWOOD WAY
LEXINGTON KY
40513-1728
US

V. Phone/Fax

Practice location:
  • Phone: 859-396-9172
  • Fax:
Mailing address:
  • Phone: 859-396-9172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number1118
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: