Provider Demographics
NPI:1669041133
Name:BAILEY KIEFFER, KATRINA LYNN (RDN, PA-C)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:LYNN
Last Name:BAILEY KIEFFER
Suffix:
Gender:F
Credentials:RDN, PA-C
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:BAILEY KIEFFER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RDN, PA-C
Mailing Address - Street 1:1218 S MIDVALE BLVD APT D
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2864
Mailing Address - Country:US
Mailing Address - Phone:719-431-0253
Mailing Address - Fax:
Practice Address - Street 1:1218 S MIDVALE BLVD APT D
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2864
Practice Address - Country:US
Practice Address - Phone:719-431-0253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86096825133V00000X
WI1185355363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86096825OtherREGISTERED DIETITIAN