Provider Demographics
NPI:1619419124
Name:BOOTH, KARA M (RD)
Entity Type:Individual
Prefix:
First Name:KARA
Middle Name:M
Last Name:BOOTH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KARA
Other - Middle Name:M
Other - Last Name:RICKETTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:35 EXECUTIVE DR
Practice Address - Street 2:SUITE 5
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-3835
Practice Address - Country:US
Practice Address - Phone:765-446-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X, 133VN1004X
IN37002863A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric