Provider Demographics
NPI:1558769307
Name:RAVILLE, KAYLEIGH (RD, CDN)
Entity Type:Individual
Prefix:MRS
First Name:KAYLEIGH
Middle Name:
Last Name:RAVILLE
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BARTON RD
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-7106
Mailing Address - Country:US
Mailing Address - Phone:518-572-4996
Mailing Address - Fax:
Practice Address - Street 1:4 BARTON RD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-7106
Practice Address - Country:US
Practice Address - Phone:518-572-4996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19031024133V00000X
NY008013133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered