Provider Demographics
NPI:1639860687
Name:MOORE, KATELYN (RD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:HAGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:595 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-4681
Mailing Address - Country:US
Mailing Address - Phone:507-430-3485
Mailing Address - Fax:
Practice Address - Street 1:595 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-4681
Practice Address - Country:US
Practice Address - Phone:507-430-3485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1286133V00000X
SD0753133V00000X
MN4475133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered