Provider Demographics
NPI:1679221220
Name:KRAFT, KATHLEEN MACKENZIE (RD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MACKENZIE
Last Name:KRAFT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24132 BREEZY POINT RD
Mailing Address - Street 2:
Mailing Address - City:ONANCOCK
Mailing Address - State:VA
Mailing Address - Zip Code:23417-2934
Mailing Address - Country:US
Mailing Address - Phone:757-710-1861
Mailing Address - Fax:
Practice Address - Street 1:204 W HILL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29404-4704
Practice Address - Country:US
Practice Address - Phone:843-963-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2377133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics