Provider Demographics
NPI:1790385938
Name:FORDEN, KYLEE MAKENNA (RDN)
Entity Type:Individual
Prefix:MS
First Name:KYLEE
Middle Name:MAKENNA
Last Name:FORDEN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 E LINCOLN DR UNIT 38
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-1020
Mailing Address - Country:US
Mailing Address - Phone:603-498-6394
Mailing Address - Fax:
Practice Address - Street 1:3800 E LINCOLN DR UNIT 38
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-1020
Practice Address - Country:US
Practice Address - Phone:603-498-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ86150477133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86150477OtherCOMMISSION ON DIETETIC REGISTRATION (CDR)