Provider Demographics
NPI:1215090741
Name:KENNEDY HUTTON, KATHLEEN M (RD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:KENNEDY HUTTON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:KENNEDY HUTTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:1741 BAINES AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1221
Mailing Address - Country:US
Mailing Address - Phone:916-717-5962
Mailing Address - Fax:916-419-2114
Practice Address - Street 1:300 HARDING BLVD
Practice Address - Street 2:SUITE 203C
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-2470
Practice Address - Country:US
Practice Address - Phone:916-717-5962
Practice Address - Fax:916-419-2114
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL819336133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered