Provider Demographics
NPI:1700414927
Name:STREETER, KATHERINE KELLY (RD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:KELLY
Last Name:STREETER
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:PO BOX 92207
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14692-0207
Mailing Address - Country:US
Mailing Address - Phone:585-683-3361
Mailing Address - Fax:
Practice Address - Street 1:90 KINIRY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-3062
Practice Address - Country:US
Practice Address - Phone:585-683-3361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
896473133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered