Basic Information
| Provider Information | |||||||||
| NPI: | 1255679973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPACH | ||||||||
| FirstName: | KATEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | RD, LD, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 7085 N CHESTNUT AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937200353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593239236 | ||||||||
| FaxNumber: | 5593230294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2013 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 963052 | CA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1006X | 963052 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic |
No ID Information.