Provider Demographics
NPI:1427629427
Name:SHALASH, IMAN
Entity type:Individual
Prefix:
First Name:IMAN
Middle Name:
Last Name:SHALASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3167 CUSTER DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4018
Mailing Address - Country:US
Mailing Address - Phone:859-388-9152
Mailing Address - Fax:859-208-2234
Practice Address - Street 1:3167 CUSTER DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4018
Practice Address - Country:US
Practice Address - Phone:859-388-9152
Practice Address - Fax:859-208-2234
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61-1251687Medicaid