Provider Demographics
NPI:1598076135
Name:GREEN, KERRY (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 N MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-2044
Mailing Address - Country:US
Mailing Address - Phone:210-415-0165
Mailing Address - Fax:
Practice Address - Street 1:265 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-2044
Practice Address - Country:US
Practice Address - Phone:210-415-0165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04664133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered