Provider Demographics
NPI:1821126582
Name:MENNILLO, KATHRYN (RD,CDN)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:
Last Name:MENNILLO
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 E. HIGH ST.
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020
Mailing Address - Country:US
Mailing Address - Phone:518-322-5083
Mailing Address - Fax:
Practice Address - Street 1:211 CHURCH ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1046
Practice Address - Country:US
Practice Address - Phone:518-583-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY960097133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered