Provider Demographics
NPI:1972480812
Name:MASSIE, KENNETH V (RDN)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:V
Last Name:MASSIE
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:V
Other - Last Name:MASSIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDN
Mailing Address - Street 1:100 MIDDLETON RD APT 47
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-3923
Mailing Address - Country:US
Mailing Address - Phone:516-675-6090
Mailing Address - Fax:
Practice Address - Street 1:100 MIDDLETON RD APT 47
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-3923
Practice Address - Country:US
Practice Address - Phone:516-675-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002496-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered