Provider Demographics
NPI:1649486226
Name:DEVINE, KATHLEEN CORNELLA (RD)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:CORNELLA
Last Name:DEVINE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 RIVERVIEW TER
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1607
Mailing Address - Country:US
Mailing Address - Phone:201-529-5680
Mailing Address - Fax:
Practice Address - Street 1:28 RIVERVIEW TER
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-1607
Practice Address - Country:US
Practice Address - Phone:201-529-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ819380133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered