Provider Demographics
NPI:1033501275
Name:BOURNE, KIA M (RDN)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:M
Last Name:BOURNE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 TREE HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-6324
Mailing Address - Country:US
Mailing Address - Phone:631-463-5666
Mailing Address - Fax:
Practice Address - Street 1:14 TREE HOLLOW LN
Practice Address - Street 2:
Practice Address - City:DIX HILLS
Practice Address - State:NY
Practice Address - Zip Code:11746-6324
Practice Address - Country:US
Practice Address - Phone:631-463-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-25
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86029217133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered