Provider Demographics
NPI:1609387679
Name:BUSACCA, KATELYN R (RD, LDN)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:R
Last Name:BUSACCA
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10026 OLD OCEAN CITY BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1288
Mailing Address - Country:US
Mailing Address - Phone:410-629-6007
Mailing Address - Fax:410-641-9515
Practice Address - Street 1:9714 HEALTHWAY DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1154
Practice Address - Country:US
Practice Address - Phone:410-641-3340
Practice Address - Fax:410-641-3341
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD86029792133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered