Provider Demographics
NPI:1154763233
Name:ANDERSON, KATHY L (RD MS, CDN, MBA)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:L
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD MS, CDN, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2504 OLINVILLE AVE
Mailing Address - Street 2:APT 1G
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-7452
Mailing Address - Country:US
Mailing Address - Phone:646-261-7091
Mailing Address - Fax:914-293-2661
Practice Address - Street 1:2504 OLINVILLE AVE
Practice Address - Street 2:APT 1G
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-7452
Practice Address - Country:US
Practice Address - Phone:646-261-7091
Practice Address - Fax:914-293-2661
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY719830133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001798OtherCD/N CERTIFIED DIETITIAN NUTRITIONIST UNIVERSITY OF THE STATE OF NEW YORK