Provider Demographics
NPI:1841779675
Name:BALKUNAS, KATHRYN LEIGH (RDN, CDE)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:LEIGH
Last Name:BALKUNAS
Suffix:
Gender:F
Credentials:RDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 JOHNNYCAKE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-2011
Mailing Address - Country:US
Mailing Address - Phone:860-484-9808
Mailing Address - Fax:
Practice Address - Street 1:500 BURLINGTON RD
Practice Address - Street 2:
Practice Address - City:HARWINTON
Practice Address - State:CT
Practice Address - Zip Code:06791-1506
Practice Address - Country:US
Practice Address - Phone:860-485-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001637133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001637OtherLICENSE