Provider Demographics
NPI:1073783098
Name:NIDES, KATHRYN M (RD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:M
Last Name:NIDES
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 1:1040 RIVER OAKS DR STE 302
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9575
Mailing Address - Country:US
Mailing Address - Phone:601-939-9923
Mailing Address - Fax:
Practice Address - Street 1:3322 W END AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-1031
Practice Address - Country:US
Practice Address - Phone:615-515-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2018133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA3A8017061Medicare PIN
LA3A801Medicare PIN