Healthcare Provider Details

I. General information

NPI: 1679221220
Provider Name (Legal Business Name): KATHLEEN MACKENZIE KRAFT RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HILL BLVD
CHARLESTON SC
29404-4704
US

IV. Provider business mailing address

24132 BREEZY POINT RD
ONANCOCK VA
23417-2934
US

V. Phone/Fax

Practice location:
  • Phone: 843-963-1110
  • Fax:
Mailing address:
  • Phone: 757-710-1861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number2377
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: