Healthcare Provider Details

I. General information

NPI: 1750259792
Provider Name (Legal Business Name): KATE MIRANDA BOURKE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 HIGHWAY 35
EATONTOWN NJ
07724-1813
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD STE 220
RED BANK NJ
07701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 885-660-4325
  • Fax: 848-300-2207
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86372624
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: