Provider Demographics
NPI:1275931560
Name:FATA, KATHERINE ELIZABETH (RD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:FATA
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 1:39475 LEWIS DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2981
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39475 LEWIS DR
Practice Address - Street 2:SUITE 110
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2981
Practice Address - Country:US
Practice Address - Phone:248-471-0675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86041573133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered