Provider Demographics
NPI:1225634843
Name:MASSEY, KASSANDRA (RDN)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:MASSEY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 SPRINGBROOK FARM RD
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-8305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1745 SPRINGBROOK FARM RD
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-8305
Practice Address - Country:US
Practice Address - Phone:828-734-5462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-09
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
NCL006309133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC133V00000XMedicaid