Provider Demographics
NPI:1619866464
Name:DEHAVEN, KAYANNA LESLIE (RDN)
Entity type:Individual
Prefix:
First Name:KAYANNA
Middle Name:LESLIE
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:KAYANNA
Other - Middle Name:LESLIE
Other - Last Name:PULLIAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN
Mailing Address - Street 1:326 S FLORES ST APT 3025
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78204-1132
Mailing Address - Country:US
Mailing Address - Phone:660-619-3306
Mailing Address - Fax:
Practice Address - Street 1:326 S FLORES ST APT 3025
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78204-1132
Practice Address - Country:US
Practice Address - Phone:660-619-3306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87725133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered