Provider Demographics
NPI:1043583719
Name:KIELICH, KATHERINE (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:KIELICH
Suffix:
Gender:F
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 BELLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1725
Mailing Address - Country:US
Mailing Address - Phone:415-847-4114
Mailing Address - Fax:
Practice Address - Street 1:51 BELLE AVE
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:CA
Practice Address - Zip Code:94930-1725
Practice Address - Country:US
Practice Address - Phone:415-847-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA999771133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered