Provider Demographics
NPI:1790126134
Name:ANDERSON, KAYLA WALD (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:WALD
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 W FARIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4254
Mailing Address - Country:US
Mailing Address - Phone:864-455-4041
Mailing Address - Fax:864-455-8447
Practice Address - Street 1:875 W FARIS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4254
Practice Address - Country:US
Practice Address - Phone:864-455-4041
Practice Address - Fax:864-455-8447
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC950133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered