Provider Demographics
NPI:1114623592
Name:GRAY, KAITLIN NICOLE (RD, CSSD, LD)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:NICOLE
Last Name:GRAY
Suffix:
Gender:F
Credentials:RD, CSSD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 65TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-7611
Mailing Address - Country:US
Mailing Address - Phone:815-742-3972
Mailing Address - Fax:
Practice Address - Street 1:2817 REILLY ST
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28310-7394
Practice Address - Country:US
Practice Address - Phone:910-570-3162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9335133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics