Provider Demographics
NPI:1275152712
Name:HOLM, KATHRYN MUNDALL (RDN, CD, CLC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MUNDALL
Last Name:HOLM
Suffix:
Gender:F
Credentials:RDN, CD, CLC
Other - Prefix:
Other - First Name:ELONNA
Other - Middle Name:
Other - Last Name:MUNDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28806 S 887 PR SE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99338-1198
Mailing Address - Country:US
Mailing Address - Phone:509-205-1018
Mailing Address - Fax:
Practice Address - Street 1:28806 S 887 PR SE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-1198
Practice Address - Country:US
Practice Address - Phone:509-205-1018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
17067174N00000X
917940133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN