Provider Demographics
NPI:1952638207
Name:KOHLEN, CORINNE ROSE (RD)
Entity Type:Individual
Prefix:
First Name:CORINNE
Middle Name:ROSE
Last Name:KOHLEN
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 1:359 LOS CERROS DR
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1272
Mailing Address - Country:US
Mailing Address - Phone:805-441-2281
Mailing Address - Fax:
Practice Address - Street 1:77 CASA ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5803
Practice Address - Country:US
Practice Address - Phone:805-548-8585
Practice Address - Fax:805-548-8589
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-06
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1001966OtherAMERICAN DIABETIC ASSOCIATION REGISTRATION
CA451935OtherNAT'L KIDNEY FOUNDATION COUNCIL ON RENAL NUTRITION MEMBER
CACQ724ZMedicare PIN