Provider Demographics
NPI:1124780481
Name:WELLS, KATHERINE (RD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:WELLS
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 1:30 N GOULD ST STE R
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-6317
Mailing Address - Country:US
Mailing Address - Phone:631-213-7190
Mailing Address - Fax:631-967-1698
Practice Address - Street 1:30 N GOULD ST STE R
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-6317
Practice Address - Country:US
Practice Address - Phone:631-213-7190
Practice Address - Fax:631-967-1698
Is Sole Proprietor?:No
Enumeration Date:2021-10-13
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009665133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered