Provider Demographics
NPI:1881252864
Name:TEAGUE, KAYLIE CHRISMON (MS, RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:KAYLIE
Middle Name:CHRISMON
Last Name:TEAGUE
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 1:5250 MOUNTAIN VIEW RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27104-5116
Mailing Address - Country:US
Mailing Address - Phone:336-391-4587
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BOULEVARD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-713-3058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004906133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86026733OtherCOMMISSION ON DIETETIC REGISTRATION
NCL004906OtherNORTH CAROLINA BOARD OF DIETETICS/NUTRITION