Provider Demographics
NPI:1326446584
Name:HEACOCK, KATHERINE (RD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:HEACOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:RODYSILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD
Mailing Address - Street 1:501 ROBERTSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-2787
Mailing Address - Country:US
Mailing Address - Phone:843-782-2692
Mailing Address - Fax:
Practice Address - Street 1:501 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2787
Practice Address - Country:US
Practice Address - Phone:843-782-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1153133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered