Healthcare Provider Details

I. General information

NPI: 1770548471
Provider Name (Legal Business Name): SHELLIE RYAN CUNNINGHAM RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLIE RYAN

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 HIGHWAY 22 E OWEN COUNTY HEALTH CENTER
OWENTON KY
40359-9041
US

IV. Provider business mailing address

510 SOUTH MAIN ST
OWENTON KY
40359
US

V. Phone/Fax

Practice location:
  • Phone: 502-732-6641
  • Fax: 502-732-8681
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberKY1563
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: