Provider Demographics
NPI:1154171916
Name:KAVANAGH, ALLISON KATHERINE (RD, LDN)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:KATHERINE
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:ALLISON
Other - Middle Name:KATHERINE
Other - Last Name:FASSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:3902 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-9412
Mailing Address - Country:US
Mailing Address - Phone:815-213-0142
Mailing Address - Fax:
Practice Address - Street 1:3902 19TH AVE
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-9412
Practice Address - Country:US
Practice Address - Phone:815-213-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.007066133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered