Provider Demographics
NPI:1275162661
Name:WOLF, KATIE JEAN (RDN)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JEAN
Last Name:WOLF
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 1ST ST
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-6079
Mailing Address - Country:US
Mailing Address - Phone:727-644-1991
Mailing Address - Fax:
Practice Address - Street 1:1001 1ST ST
Practice Address - Street 2:
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-6079
Practice Address - Country:US
Practice Address - Phone:727-644-1991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL86147720133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered