Provider Demographics
NPI:1255507778
Name:SHAFER, KATHLEEN M (MA, RD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:SHAFER
Suffix:
Gender:F
Credentials:MA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 B GALE WILSON BLVD
Mailing Address - Street 2:NUTRITION SERVICES AT NORTHBAY HEALTHCARE
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533
Mailing Address - Country:US
Mailing Address - Phone:707-429-7870
Mailing Address - Fax:
Practice Address - Street 1:1200 B GALE WILSON BLVD
Practice Address - Street 2:NUTRITION SERVICES AT NORTHBAY HEALTHCARE
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-429-7870
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719448133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered