Provider Demographics
NPI:1558492223
Name:BREWER, KATHLEEN F
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:F
Last Name:BREWER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FLORENCE
Other - Middle Name:KATHLEEN RAE
Other - Last Name:BLIVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1028 BLOSSOM CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-9520
Mailing Address - Country:US
Mailing Address - Phone:541-679-4723
Mailing Address - Fax:
Practice Address - Street 1:2459 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1596
Practice Address - Country:US
Practice Address - Phone:541-677-2102
Practice Address - Fax:541-677-4848
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24118133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000ZGBFMMedicare ID - Type UnspecifiedMEDICARE GROUP NUMBER