Provider Demographics
NPI:1245787605
Name:BENNETT, KATHERINE (RD MPH CLEC)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:RD MPH CLEC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 ELDEN AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2152 ELDEN AVE APT 6
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1730
Practice Address - Country:US
Practice Address - Phone:949-838-7188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered