Provider Demographics
NPI:1710536339
Name:LEAHY, KATELYN ANN (MS, RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:ANN
Last Name:LEAHY
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:MISS
Other - First Name:KATELYN
Other - Middle Name:ANN
Other - Last Name:FLEWELLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4614 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-3520
Mailing Address - Country:US
Mailing Address - Phone:336-716-6099
Mailing Address - Fax:
Practice Address - Street 1:3903 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27455-2877
Practice Address - Country:US
Practice Address - Phone:336-716-6099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8808133V00000X
NCL005920133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered