Provider Demographics
NPI:1467875609
Name:KAUFMANN, MARY GANNON (RD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GANNON
Last Name:KAUFMANN
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 1:7124 CHELSEA DR NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1471
Mailing Address - Country:US
Mailing Address - Phone:319-447-1381
Mailing Address - Fax:
Practice Address - Street 1:1026 A AVE NE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5036
Practice Address - Country:US
Practice Address - Phone:319-369-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA002182Medicare PIN