Provider Demographics
NPI:1669694576
Name:MACDONALD, KATHLEEN ANN (MSRDCD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:MSRDCD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MACDONALD
Other - Last Name:BEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12040 NE 128TH ST
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3013
Mailing Address - Country:US
Mailing Address - Phone:425-899-1550
Mailing Address - Fax:
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000976133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI00000976OtherDIETITIAN LICENSE