Provider Demographics
NPI:1982292082
Name:MATHERLY, JAMES (RD, LD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:MATHERLY
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:438 BASHORE DR
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25404-7603
Mailing Address - Country:US
Mailing Address - Phone:304-546-6094
Mailing Address - Fax:
Practice Address - Street 1:118 E OAK RIDGE DR STE 1100
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-7793
Practice Address - Country:US
Practice Address - Phone:240-382-1312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX5156133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered