Provider Demographics
NPI:1134604564
Name:COSTA, KAITLIN SHAY (RD, LDN)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:SHAY
Last Name:COSTA
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:SHAY
Other - Last Name:FITZPATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LDN
Mailing Address - Street 1:441 READ ST
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-3048
Mailing Address - Country:US
Mailing Address - Phone:508-954-5893
Mailing Address - Fax:
Practice Address - Street 1:441 READ ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02726-3048
Practice Address - Country:US
Practice Address - Phone:508-954-5893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4315133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered