Provider Demographics
NPI:1164949541
Name:GREB, KAITLYN (RDLD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GREB
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1391
Mailing Address - Street 2:
Mailing Address - City:PANHANDLE
Mailing Address - State:TX
Mailing Address - Zip Code:79068-1391
Mailing Address - Country:US
Mailing Address - Phone:479-518-0711
Mailing Address - Fax:
Practice Address - Street 1:3023 PERRYTON PKWY STE 101
Practice Address - Street 2:
Practice Address - City:PAMPA
Practice Address - State:TX
Practice Address - Zip Code:79065-2817
Practice Address - Country:US
Practice Address - Phone:806-665-0801
Practice Address - Fax:806-665-8503
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84769133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDT84769OtherLICENSE NUMBER