Provider Demographics
NPI:1386031193
Name:MANCEBO, KATRINA C (RD)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:C
Last Name:MANCEBO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:
Other - Last Name:STEPHANIDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:16 FRONT ST STE 209
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MA
Mailing Address - Zip Code:01970-3743
Mailing Address - Country:US
Mailing Address - Phone:978-927-0990
Mailing Address - Fax:866-921-9387
Practice Address - Street 1:16 FRONT ST STE 209
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-3743
Practice Address - Country:US
Practice Address - Phone:978-927-0990
Practice Address - Fax:866-921-9387
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3383133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered