Provider Demographics
NPI:1700654480
Name:MATHEWS, KATHERINE MCKENNA (RDN, CDN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MCKENNA
Last Name:MATHEWS
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2039 STATE ROUTE 245
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14561-9568
Mailing Address - Country:US
Mailing Address - Phone:607-857-9823
Mailing Address - Fax:
Practice Address - Street 1:2 COULTER RD STE 1620
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1122
Practice Address - Country:US
Practice Address - Phone:315-462-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered