Provider Demographics
NPI:1952616146
Name:HARRISON, KATHLEEN MARIE (MSRD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:MSRD
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSRD
Mailing Address - Street 1:5938 BRITTANY WAY
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-6713
Mailing Address - Country:US
Mailing Address - Phone:916-961-0290
Mailing Address - Fax:916-961-0290
Practice Address - Street 1:2025 P ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-5213
Practice Address - Country:US
Practice Address - Phone:916-446-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR413699133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered