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General NPI Number Information
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NPI Number | 1174032478
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Entity Type | Individual
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Provider Name | MARY KATHRYN AUSICH RD, CDE
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Gender | Female
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Dates
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Enumeration Date | 09/29/2017
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Last Update Date | 07/16/2020
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Provider Practice Location Address
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Address Line | 7901 S 12TH ST STE 200
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City | PORTAGE
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State | MI
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Zip | 49024-3831
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Country | US
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Telephone | 269-341-8585
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Fax |
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Provider Business Mailing Address
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Address Line | 601 JOHN STREET BOX 39
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City | KALAMAZOO
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State | MI
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Zip | 49007
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 1024516
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License Number State |
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