Provider Demographics
NPI:1316372709
Name:BLACK, KATIE RENE (RD)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:RENE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 BEARBERRY CIR
Mailing Address - Street 2:APT 203
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33559-8772
Mailing Address - Country:US
Mailing Address - Phone:775-857-9136
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered