Provider Demographics
NPI:1033439591
Name:KINSELLA, THERESA (MS, RD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KINSELLA
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 BOUCHER AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-2306
Mailing Address - Country:US
Mailing Address - Phone:646-351-9148
Mailing Address - Fax:646-666-4405
Practice Address - Street 1:280 MADISON AVE
Practice Address - Street 2:SUITE 1004
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:646-351-9148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005797-1133V00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered