Provider Demographics
NPI:1720501166
Name:FITZGERALD, KAYLA NICOLE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:NICOLE
Last Name:FITZGERALD
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 1:831 RIVERTON WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3480
Mailing Address - Country:US
Mailing Address - Phone:843-508-4726
Mailing Address - Fax:
Practice Address - Street 1:831 RIVERTON WAY
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3480
Practice Address - Country:US
Practice Address - Phone:843-508-4726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
SC1641133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered