Provider Demographics
NPI:1245791664
Name:BREAZEALE, KATIE RENEE (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:RENEE
Last Name:BREAZEALE
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:TX
Mailing Address - Zip Code:76513-2049
Mailing Address - Country:US
Mailing Address - Phone:254-718-8068
Mailing Address - Fax:
Practice Address - Street 1:403 DOWNING ST
Practice Address - Street 2:
Practice Address - City:BELTON
Practice Address - State:TX
Practice Address - Zip Code:76513-2049
Practice Address - Country:US
Practice Address - Phone:254-718-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2024-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85821133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered