Basic Information
| Provider Information | |||||||||
| NPI: | 1316488703 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KATIE DEFOE-RAYMOND | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2 MEDICAL CENTER DR | ||||||||
| Address2: | STE 404 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137363163 | ||||||||
| FaxNumber: | 4137330206 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MEDICAL CENTER DR | ||||||||
| Address2: | STE 404 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011071270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137363163 | ||||||||
| FaxNumber: | 4137330206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2017 | ||||||||
| LastUpdateDate: | 03/17/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DEFOE-RAYMOND | ||||||||
| AuthorizedOfficialFirstName: | KATIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/AUTHORIZED OFFCIAL | ||||||||
| AuthorizedOfficialTelephone: | 4135753048 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.