Provider Demographics
NPI:1073116646
Name:BASTIAN, KATIE (MDA, RDN, SNS)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BASTIAN
Suffix:
Gender:F
Credentials:MDA, RDN, SNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13833 S OXFORDSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFDALE
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6056
Mailing Address - Country:US
Mailing Address - Phone:801-450-9901
Mailing Address - Fax:
Practice Address - Street 1:7905 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-4601
Practice Address - Country:US
Practice Address - Phone:801-567-8602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7236722-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered