Provider Demographics
NPI:1922509561
Name:RZASA, KAITLYN (MS, RDN, LDN)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:RZASA
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 MADISON AVE APT G
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-9399
Mailing Address - Country:US
Mailing Address - Phone:815-685-0994
Mailing Address - Fax:
Practice Address - Street 1:101 E 9TH ST
Practice Address - Street 2:
Practice Address - City:PANA
Practice Address - State:IL
Practice Address - Zip Code:62557-1716
Practice Address - Country:US
Practice Address - Phone:217-562-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL86067136133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered