Provider Demographics
NPI:1073215299
Name:HACKL, KATELYNN MARIE (RDN)
Entity Type:Individual
Prefix:
First Name:KATELYNN
Middle Name:MARIE
Last Name:HACKL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 CROWN BAY MARINA
Mailing Address - Street 2:PMB 159
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00802
Mailing Address - Country:US
Mailing Address - Phone:920-883-0559
Mailing Address - Fax:
Practice Address - Street 1:5316 YACHT HAVEN GRANDE
Practice Address - Street 2:BUILDING N SUITE 101
Practice Address - City:ST THOMAS
Practice Address - State:VI
Practice Address - Zip Code:00802
Practice Address - Country:US
Practice Address - Phone:340-244-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-21
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI86174855133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered