Provider Demographics
NPI:1144396599
Name:KURACINA, THERESA ANN (RD)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:KURACINA
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 1:801 VASSAR DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2725
Mailing Address - Country:US
Mailing Address - Phone:505-248-7619
Mailing Address - Fax:505-248-7698
Practice Address - Street 1:801 VASSAR DR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2725
Practice Address - Country:US
Practice Address - Phone:505-248-7619
Practice Address - Fax:505-248-7698
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM092133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14909367Medicaid