Provider Demographics
NPI:1578194882
Name:GORDON, KATHLIN MAREA (RDN, CDE)
Entity Type:Individual
Prefix:MS
First Name:KATHLIN
Middle Name:MAREA
Last Name:GORDON
Suffix:
Gender:F
Credentials:RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 COLISEUM DR STE 420
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5904
Mailing Address - Country:US
Mailing Address - Phone:757-827-2275
Mailing Address - Fax:757-827-2173
Practice Address - Street 1:4000 COLISEUM DR STE 420
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5904
Practice Address - Country:US
Practice Address - Phone:757-827-2275
Practice Address - Fax:757-827-2173
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA86026233133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered