Provider Demographics
NPI:1700052438
Name:TYRRELL, KATHERINE (RD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:TYRRELL
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 1:555 SAINT CLAIR RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ALGONAC
Mailing Address - State:MI
Mailing Address - Zip Code:48001-1802
Mailing Address - Country:US
Mailing Address - Phone:810-794-4982
Mailing Address - Fax:810-794-4407
Practice Address - Street 1:58144 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:MI
Practice Address - Zip Code:48048
Practice Address - Country:US
Practice Address - Phone:810-794-4982
Practice Address - Fax:810-794-4407
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI988928133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered