Provider Demographics
NPI:1457965030
Name:JOHNSON, KAITLYN RAE (RD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:RAE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:
Other - Last Name:LIVINGSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-0708
Mailing Address - Country:US
Mailing Address - Phone:307-746-8353
Mailing Address - Fax:
Practice Address - Street 1:7717 IVY LANE
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80549-8054
Practice Address - Country:US
Practice Address - Phone:307-746-8353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86017688133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered