Provider Demographics
NPI:1932980349
Name:MINAMOTO WEBB, KOUKA
Entity Type:Individual
Prefix:
First Name:KOUKA
Middle Name:
Last Name:MINAMOTO WEBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KOUKA
Other - Middle Name:ORPHELIA
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, RD
Mailing Address - Street 1:305 E 24TH ST APT 20M
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-4061
Mailing Address - Country:US
Mailing Address - Phone:917-945-2206
Mailing Address - Fax:
Practice Address - Street 1:305 E 24TH ST APT 20M
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4061
Practice Address - Country:US
Practice Address - Phone:917-945-2206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86198157133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered