Provider Demographics
NPI:1053041574
Name:DUBOIS, MARY KATHRIN (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRIN
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34162 CAPISTRANO BY THE SEA
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-2940
Mailing Address - Country:US
Mailing Address - Phone:194-924-0433
Mailing Address - Fax:949-240-4392
Practice Address - Street 1:34162 CAPISTRANO BY THE SEA
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-2940
Practice Address - Country:US
Practice Address - Phone:949-240-4343
Practice Address - Fax:949-240-4392
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA722761133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered