Provider Demographics
NPI:1689333890
Name:KYLE, COURTNEY (MS, RD, CD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:KYLE
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 N WILLAMETTE RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99016-5058
Mailing Address - Country:US
Mailing Address - Phone:509-671-2462
Mailing Address - Fax:
Practice Address - Street 1:1761 N WILLAMETTE RD
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99016-5058
Practice Address - Country:US
Practice Address - Phone:509-671-2462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61141161133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered