Provider Demographics
NPI:1285813287
Name:BUNDY, KATHLEEN CARMELA (RD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CARMELA
Last Name:BUNDY
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:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:800-926-8273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-26
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA916954133V00000X
WADI00002034133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA3349BUOtherBLUE SHIELD # VM
WA0039581OtherLABOR AND INDUSTRIES # VM