Provider Demographics
NPI:1922323336
Name:WERTHER, KATHLEEN ANN (RD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:WERTHER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0182
Mailing Address - Country:US
Mailing Address - Phone:516-317-2264
Mailing Address - Fax:
Practice Address - Street 1:DEPARTMENT OF CLINICAL NUTRITION RM 747A LEVEL 1
Practice Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-7008
Practice Address - Country:US
Practice Address - Phone:631-444-1442
Practice Address - Fax:631-632-2690
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000658-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered