Healthcare Provider Details

I. General information

NPI: 1023639051
Provider Name (Legal Business Name): ALEXANDRA JOE DEPRIEST RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E LIBERTY ST
LOUISVILLE KY
40202-1530
US

IV. Provider business mailing address

228 RING RD
LOUISVILLE KY
40207-3436
US

V. Phone/Fax

Practice location:
  • Phone: 502-587-4465
  • Fax:
Mailing address:
  • Phone: 502-718-1135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number245493
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: