Healthcare Provider Details

I. General information

NPI: 1215090741
Provider Name (Legal Business Name): KATHLEEN M. KENNEDY HUTTON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHLEEN M. KENNEDY HUTTON RD

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HARDING BLVD SUITE 203C
ROSEVILLE CA
95678-2470
US

IV. Provider business mailing address

1741 BAINES AVE
SACRAMENTO CA
95835-1221
US

V. Phone/Fax

Practice location:
  • Phone: 916-717-5962
  • Fax: 916-419-2114
Mailing address:
  • Phone: 916-717-5962
  • Fax: 916-419-2114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number819336
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: