Provider Demographics
NPI:1316959232
Name:JOSEPHSON, KAY (RD)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:JOSEPHSON
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 1:516 E. NIZHONI BLVD.
Mailing Address - Street 2:BOX 1337
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:505-722-1496
Practice Address - Street 1:516 E. NIZHONI BLVD.
Practice Address - Street 2:BOX 1337
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-1337
Practice Address - Country:US
Practice Address - Phone:505-722-1464
Practice Address - Fax:505-722-1496
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06506133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM04688261Medicaid
TX8HD550Medicare ID - Type Unspecified
Q41466Medicare UPIN