Provider Demographics
NPI:1164886602
Name:DORMAN, KAITLIN GRACE (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:GRACE
Last Name:DORMAN
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:GRACE
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD,, LDN
Mailing Address - Street 1:501 6TH AVENUE SOUTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710
Mailing Address - Country:US
Mailing Address - Phone:727-767-7204
Mailing Address - Fax:
Practice Address - Street 1:501 6TH AVE S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4634
Practice Address - Country:US
Practice Address - Phone:727-767-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 7527133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered