Provider Demographics
NPI:1922022979
Name:DETAMORE, KATHLEEN SUE (RD, LD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUE
Last Name:DETAMORE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 TOWNSHIP ROAD 900
Mailing Address - Street 2:
Mailing Address - City:WEST SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44287-8729
Mailing Address - Country:US
Mailing Address - Phone:419-869-7527
Mailing Address - Fax:
Practice Address - Street 1:55 W WATERLOO RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44319-1116
Practice Address - Country:US
Practice Address - Phone:330-724-7715
Practice Address - Fax:330-724-1080
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5709133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered