Basic Information
| Provider Information | |||||||||
| NPI: | 1922497957 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CANNON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | CLIFTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANNON | ||||||||
| OtherFirstName: | KATE | ||||||||
| OtherMiddleName: | C | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 18563 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276198563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197821806 | ||||||||
| FaxNumber: | 9197824756 | ||||||||
| Practice Location | |||||||||
| Address1: | 3521 HAWORTH DR | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276097244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197821806 | ||||||||
| FaxNumber: | 9197824756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2015 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | L003467 | NC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.