Provider Demographics
NPI:1841752292
Name:ROGERS, KATIE LEIGH (RD, LD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LEIGH
Last Name:ROGERS
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 1:607 SE 17TH AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2600
Mailing Address - Country:US
Mailing Address - Phone:971-259-3759
Mailing Address - Fax:
Practice Address - Street 1:2143 NE BROADWAY ST # 9
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1512
Practice Address - Country:US
Practice Address - Phone:971-259-3759
Practice Address - Fax:971-402-9020
Is Sole Proprietor?:No
Enumeration Date:2019-04-04
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10186235133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLD-D-10186235OtherSTATE LICENSE NUMBER
86085814OtherCOMMISSION ON DIETETIC REGISTRATION
WADI61358765OtherSTATE LICENSURE WA