Provider Demographics
NPI:1710572409
Name:KATE CONKLIN, REGISTERED DIETITIAN, LLC
Entity Type:Organization
Organization Name:KATE CONKLIN, REGISTERED DIETITIAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, LDN
Authorized Official - Phone:860-833-7162
Mailing Address - Street 1:321 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:PA
Mailing Address - Zip Code:18447-1205
Mailing Address - Country:US
Mailing Address - Phone:860-833-7162
Mailing Address - Fax:
Practice Address - Street 1:321 1ST ST
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:PA
Practice Address - Zip Code:18447-1205
Practice Address - Country:US
Practice Address - Phone:860-833-7162
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN007174OtherPENNSYLVANIA BOARD OF NURSING