Provider Demographics
NPI:1962772442
Name:LEGARE, KATHLEEN J (RD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:LEGARE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:J
Other - Last Name:HECKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-5509
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2405133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered