Provider Demographics
NPI:1982095675
Name:WHITE, KATHLEEN (MS,RD)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 BIRCHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-2117
Mailing Address - Country:US
Mailing Address - Phone:201-441-9970
Mailing Address - Fax:201-441-9979
Practice Address - Street 1:155 POLIFLY RD
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1758
Practice Address - Country:US
Practice Address - Phone:201-441-9970
Practice Address - Fax:201-441-9979
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ708050133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric