Provider Demographics
NPI:1750527198
Name:REILY, KATHLEEN K (RD, CDE)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:K
Last Name:REILY
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8640 SUDLEY RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4420
Mailing Address - Country:US
Mailing Address - Phone:703-369-8616
Mailing Address - Fax:703-369-8533
Practice Address - Street 1:8640 SUDLEY RD
Practice Address - Street 2:SUITE 108
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4420
Practice Address - Country:US
Practice Address - Phone:703-369-8616
Practice Address - Fax:703-369-8533
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY491168133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered