Healthcare Provider Details

I. General information

NPI: 1558420877
Provider Name (Legal Business Name): KATHLEEN A. FELLABAUM R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 INKSTER RD DIABETES SELF MGMT EDUCATION, GARDEN CITY HOSPITAL
GARDEN CITY MI
48135-4001
US

IV. Provider business mailing address

5677 WINSLOW CT
YPSILANTI MI
48197-9021
US

V. Phone/Fax

Practice location:
  • Phone: 734-458-4330
  • Fax: 734-458-4690
Mailing address:
  • Phone: 734-528-9063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberNONE
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: