Provider Demographics
NPI:1003460882
Name:HETTICH, KYNDAL LYN (RD, CSP, CD)
Entity Type:Individual
Prefix:
First Name:KYNDAL
Middle Name:LYN
Last Name:HETTICH
Suffix:
Gender:F
Credentials:RD, CSP, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 N PROSPECT AVE APT 706
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-2421
Mailing Address - Country:US
Mailing Address - Phone:414-688-6339
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-5938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered