Healthcare Provider Details

I. General information

NPI: 1790221984
Provider Name (Legal Business Name): KATHLEEN MARY BUMP RDN, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HALTON RD
SYRACUSE NY
13224-2228
US

IV. Provider business mailing address

300 HALTON RD
SYRACUSE NY
13224-2228
US

V. Phone/Fax

Practice location:
  • Phone: 315-380-7545
  • Fax:
Mailing address:
  • Phone: 315-380-7545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number48008881
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: