Provider Demographics
NPI:1346993730
Name:WILSON, KATHRYN CLARE (MS, RD, LDN, CNSC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:CLARE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, LDN, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SAINT GERMAIN ST APT 7
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-3232
Mailing Address - Country:US
Mailing Address - Phone:860-303-4222
Mailing Address - Fax:
Practice Address - Street 1:19 SAINT GERMAIN ST APT 7
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-3232
Practice Address - Country:US
Practice Address - Phone:860-303-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4877133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered