Provider Demographics
NPI:1972959229
Name:O'MARA, KATIE (RD, CLE)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:
Last Name:O'MARA
Suffix:
Gender:F
Credentials:RD, CLE
Other - Prefix:MRS
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:O'MARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, CLE
Mailing Address - Street 1:34462 CALLE CARMELITA
Mailing Address - Street 2:
Mailing Address - City:CAPISTRANO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92624-1022
Mailing Address - Country:US
Mailing Address - Phone:916-955-9429
Mailing Address - Fax:
Practice Address - Street 1:34462 CALLE CARMELITA
Practice Address - Street 2:
Practice Address - City:CAPISTRANO BEACH
Practice Address - State:CA
Practice Address - Zip Code:92624-1022
Practice Address - Country:US
Practice Address - Phone:916-955-9429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1034742133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered