Provider Demographics
NPI:1356992937
Name:CALLAHAN, KATHRYN WILLIS (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:WILLIS
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 W AMERICANA TER
Mailing Address - Street 2:STE 215
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2545
Mailing Address - Country:US
Mailing Address - Phone:208-629-2441
Mailing Address - Fax:
Practice Address - Street 1:3350 W AMERICANA TER
Practice Address - Street 2:STE 215
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2545
Practice Address - Country:US
Practice Address - Phone:208-629-2441
Practice Address - Fax:208-342-0667
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1152133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered