Provider Demographics
NPI:1427435999
Name:KOETTER-ALI, MAJEDAH Y (RD)
Entity type:Individual
Prefix:
First Name:MAJEDAH
Middle Name:Y
Last Name:KOETTER-ALI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MAJI
Other - Middle Name:
Other - Last Name:ALI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:907 LYNDON LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-3815
Mailing Address - Country:US
Mailing Address - Phone:502-425-7659
Mailing Address - Fax:502-425-7658
Practice Address - Street 1:907 LYNDON LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-3815
Practice Address - Country:US
Practice Address - Phone:502-425-7659
Practice Address - Fax:502-425-7658
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBDNDTN00218429133V00000X
KY162884133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000945941OtherANTHEM
KYK134300Medicare PIN