MEDICARE: MRS. KATHRYN ALLYSON BUSH RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	DT88965	TX
2	133V00000X	Registered Dietitian	086065832

General Provider Information

NPI Number	:	1245073097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHRYN ALLYSON BUSH RDN

Provider Business Mailing Address
First Line	:	6328 BATTLE MOUNTAIN TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-2155
Country	:	US
Telephone Number	:	817-980-2713
Fax Number	:

Provider Business Practice Location Address
First Line	:	6328 BATTLE MOUNTAIN TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-2155
Country	:	US
Telephone Number	:	817-980-2713
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/18/2024
Last Update Date	:	06/18/2024

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