Provider Demographics
NPI:1689272965
Name:JOHN, KATELYN DIANE (RDN, LD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:DIANE
Last Name:JOHN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 N CLITHERO DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5703
Mailing Address - Country:US
Mailing Address - Phone:717-683-3373
Mailing Address - Fax:
Practice Address - Street 1:967 N CLITHERO DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5703
Practice Address - Country:US
Practice Address - Phone:717-683-3373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2023-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1159133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered