Provider Demographics
NPI:1053437699
Name:MASON, KATHLEEN M (LRD)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:M
Last Name:MASON
Suffix:
Gender:F
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 GROVE ST N
Mailing Address - Street 2:
Mailing Address - City:CANNON FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:55009-2230
Mailing Address - Country:US
Mailing Address - Phone:507-332-4734
Mailing Address - Fax:507-332-4848
Practice Address - Street 1:200 STATE AVE
Practice Address - Street 2:DISTRICT ONE HOSPITAL
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-332-4734
Practice Address - Fax:507-332-4848
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1228133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered