Provider Demographics
NPI:1740602796
Name:BIANCONI, KATELYN MUSTAIN (RD)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MUSTAIN
Last Name:BIANCONI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 59002
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37950-9002
Mailing Address - Country:US
Mailing Address - Phone:865-588-5121
Mailing Address - Fax:
Practice Address - Street 1:1311 DOWELL SPRINGS BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-2454
Practice Address - Country:US
Practice Address - Phone:865-588-5121
Practice Address - Fax:865-588-5126
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2486133V00000X
TNLDN2861133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2486OtherLOUISIANA LICENSE NUTRITION AND DIETETICS
TN2861OtherLICENSED DIETITIAN NUTRITIONIST