Provider Demographics
NPI:1609520832
Name:KHOSRAVIPOUR, KAITLYN (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KAITLYN
Middle Name:
Last Name:KHOSRAVIPOUR
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:MS
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:KOHNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:3612 S OLD PINK HILL RD
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:64075-7326
Mailing Address - Country:US
Mailing Address - Phone:816-929-4460
Mailing Address - Fax:
Practice Address - Street 1:2401 GILLHAM RD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-4619
Practice Address - Country:US
Practice Address - Phone:816-648-2510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2685133V00000X
MO2021019030133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered