Provider Demographics
NPI:1659349637
Name:BROCKWAY, KATHY (RD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:BROCKWAY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:KATHY
Other - Middle Name:C
Other - Last Name:BROCKWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD CDE
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:269-341-8585
Mailing Address - Fax:269-341-7518
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007
Practice Address - Country:US
Practice Address - Phone:269-341-8585
Practice Address - Fax:269-341-7518
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI502450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered