Provider Demographics
NPI:1255980611
Name:SHERIDAN, KATHRYN S (RD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:S
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 CROSSPOINT APT 4104
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-3110
Mailing Address - Country:US
Mailing Address - Phone:937-776-4418
Mailing Address - Fax:
Practice Address - Street 1:1920 HARRY WURZBACH RD BLDG 1620
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-6025
Practice Address - Country:US
Practice Address - Phone:937-776-4418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86007969133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE