Provider Demographics
NPI:1073619557
Name:GREEN, KATHERINE ANNE (RD/LD)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANNE
Last Name:GREEN
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11124 CACTUS LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238-3802
Mailing Address - Country:US
Mailing Address - Phone:972-679-1463
Mailing Address - Fax:
Practice Address - Street 1:1935 MOTOR ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-2133
Practice Address - Fax:214-456-6287
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07680133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric