Provider Demographics
NPI:1174108955
Name:STODDARD, MARY ANN (RD)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:STODDARD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 SPRINGSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-3786
Mailing Address - Country:US
Mailing Address - Phone:502-939-4465
Mailing Address - Fax:502-365-4629
Practice Address - Street 1:1301 CLEAR SPRINGS TRCE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-3855
Practice Address - Country:US
Practice Address - Phone:502-365-4627
Practice Address - Fax:502-365-4629
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1340133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered