Basic Information
| Provider Information | |||||||||
| NPI: | 1538117759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLAYDON | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2830 VICTORY PKWY | ||||||||
| Address2: | STE 310 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452063700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132453444 | ||||||||
| FaxNumber: | 5132453449 | ||||||||
| Practice Location | |||||||||
| Address1: | 3120 BURNET AVE | ||||||||
| Address2: | STE 306 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293091 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134758200 | ||||||||
| FaxNumber: | 5134758201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD1587 | OH | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | PO0299764 | 01 | OH | RRMEDICARE | OTHER |