Provider Demographics
NPI:1255939146
Name:KLUG, KATIE NICOLE (RD)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:NICOLE
Last Name:KLUG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:NICOLE
Other - Last Name:PAVLICEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:701-456-4866
Practice Address - Street 1:2615 FAIRWAY ST
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-2590
Practice Address - Country:US
Practice Address - Phone:701-456-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1155133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered