Provider Demographics
NPI:1306413190
Name:FAUST, KYLIE R (RD, LDN)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:R
Last Name:FAUST
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3004
Mailing Address - Country:US
Mailing Address - Phone:814-643-7054
Mailing Address - Fax:
Practice Address - Street 1:1225 WARM SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:16652-2350
Practice Address - Country:US
Practice Address - Phone:814-643-7054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN007372133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN007372OtherBUREAU OF PROFESSIONAL AND OCCUPATIONAL AFFAIRS
86102711OtherCOMMISSION ON DIETETIC REGISTRATION