1689104606 NPI number — KACEY MARALYN LEGNITTO MS, RD, CEDRD

Table of content: KACEY MARALYN LEGNITTO MS, RD, CEDRD (NPI 1689104606)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689104606 NPI number — KACEY MARALYN LEGNITTO MS, RD, CEDRD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEGNITTO
Provider First Name:
KACEY
Provider Middle Name:
MARALYN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, CEDRD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEGNITTO
Provider Other First Name:
KACEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RD, CEDRD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1689104606
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2832, 1070 COLUMBUS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL GRANADA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-416-6533
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 TAMAL PLZ STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORTE MADERA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94925-1195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-416-6533
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  86031562 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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