Provider Demographics
NPI:1154847374
Name:WONG, KAITLYN (RD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 E COUNTY LINE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1074
Mailing Address - Country:US
Mailing Address - Phone:317-957-9050
Mailing Address - Fax:
Practice Address - Street 1:533 E COUNTY LINE RD STE 101
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-1074
Practice Address - Country:US
Practice Address - Phone:317-957-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37002417A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered