Provider Demographics
NPI:1275639189
Name:HODNETT, MARY KATHRYN REESE (RD)
Entity Type:Individual
Prefix:
First Name:MARY KATHRYN
Middle Name:REESE
Last Name:HODNETT
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 1:1906 BELLEVIEW AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 S JEFFERSON ST
Practice Address - Street 2:SUITE 416
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24011-1705
Practice Address - Country:US
Practice Address - Phone:540-224-5680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL702573133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL702573OtherCERTIFICATION NUMBER