Provider Demographics
NPI:1114257037
Name:SQUIRES, KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:SQUIRES
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:SQUIRES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:50 NICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:VT
Mailing Address - Zip Code:05345
Mailing Address - Country:US
Mailing Address - Phone:802-365-7388
Mailing Address - Fax:
Practice Address - Street 1:50 NICHOLS RD
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:VT
Practice Address - Zip Code:05345-9594
Practice Address - Country:US
Practice Address - Phone:802-365-7388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT074000145133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered