Provider Demographics
NPI:1043031339
Name:HICKEY, KATHLEEN MARIE (RDN LDN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:HICKEY
Suffix:
Gender:F
Credentials:RDN LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-3418
Mailing Address - Country:US
Mailing Address - Phone:781-307-0046
Mailing Address - Fax:
Practice Address - Street 1:168 WOODCREST DR
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3418
Practice Address - Country:US
Practice Address - Phone:781-307-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL008181133V00000X
MALDN7654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered