Healthcare Provider Details

I. General information

NPI: 1528126729
Provider Name (Legal Business Name): KAY ELIZABETH CORCORAN RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAY ELIZABETH MCKINNIE RD, LD

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040A JACKSON AVENUE NUTRITION CARE DIVISION
JBLM WA
98431-8952
US

IV. Provider business mailing address

9040A JACKSON AVENUE NUTRITION CARE DIVISION
JBLM WA
98431
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0549
  • Fax:
Mailing address:
  • Phone: 253-968-0549
  • Fax: 573-596-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDI609989935
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: