Basic Information
Provider Information | |||||||||
NPI: | 1578903704 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OWENS | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 405 MONROE ST | ||||||||
Address2: |   | ||||||||
City: | PELLA | ||||||||
State: | IA | ||||||||
PostalCode: | 502191189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6416283832 | ||||||||
FaxNumber: | 6416212335 | ||||||||
Practice Location | |||||||||
Address1: | 405 MONROE ST | ||||||||
Address2: |   | ||||||||
City: | PELLA | ||||||||
State: | IA | ||||||||
PostalCode: | 502191189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6416283832 | ||||||||
FaxNumber: | 6416212335 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2013 | ||||||||
LastUpdateDate: | 07/02/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 01404 | IA | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | 01404 | 01 | IA | STATE LICENSE | OTHER |