Healthcare Provider Details

I. General information

NPI: 1942851159
Provider Name (Legal Business Name): KATHRYN LEE SIDHU RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN LEE RESKE RDN, IBCLC

II. Dates (important events)

Enumeration Date: 09/28/2019
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1159 SECRET PL
GREENBANK WA
98253-9782
US

IV. Provider business mailing address

1159 SECRET PL
GREENBANK WA
98253-9782
US

V. Phone/Fax

Practice location:
  • Phone: 765-635-5861
  • Fax:
Mailing address:
  • Phone: 765-635-5861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-306122
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86075534
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: