Provider Demographics
NPI:1902671191
Name:DURSTON, KATHRYN NOELLE (RDN)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:NOELLE
Last Name:DURSTON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 WILBUR ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-3326
Mailing Address - Country:US
Mailing Address - Phone:616-307-9624
Mailing Address - Fax:
Practice Address - Street 1:115 WILBUR ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-3326
Practice Address - Country:US
Practice Address - Phone:616-307-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86360639133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty