Provider Demographics
NPI:1619683729
Name:DOUGLAS, KATHERINE (RD/RDN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RD/RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 GLENEAGLE GRANDE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32124-3044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11555 CENTRAL PKWY STE 201
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2693
Practice Address - Country:US
Practice Address - Phone:904-300-2809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered