Provider Demographics
NPI:1851745657
Name:MATHLIN, KATIE ELLEN (RDN)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELLEN
Last Name:MATHLIN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ELLEN
Other - Last Name:FERGUSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15 RYE ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-6829
Mailing Address - Country:US
Mailing Address - Phone:774-282-0364
Mailing Address - Fax:
Practice Address - Street 1:15 RYE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-6829
Practice Address - Country:US
Practice Address - Phone:774-282-0364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0689133V00000X
RILDN00898133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered