Healthcare Provider Details

I. General information

NPI: 1346213212
Provider Name (Legal Business Name): KINDERHOOK NUTRITION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 ROTHERMEL AVE
KINDERHOOK NY
12106-2105
US

IV. Provider business mailing address

PO BOX 3
KINDERHOOK NY
12106-0003
US

V. Phone/Fax

Practice location:
  • Phone: 518-758-8885
  • Fax: 518-758-9390
Mailing address:
  • Phone: 518-758-8885
  • Fax: 518-758-9390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number006035-1
License Number StateNY

VIII. Authorized Official

Name: KELLY VANALLEN-BRASWELL
Title or Position: PRESIDENT
Credential: RD
Phone: 518-758-8885