Provider Demographics
NPI:1932723194
Name:ALLEN, KAITLYN SUE (RD)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:SUE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 S BEACH BLVD APT D403
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-1160
Mailing Address - Country:US
Mailing Address - Phone:623-466-2090
Mailing Address - Fax:
Practice Address - Street 1:1501 S BEACH BLVD APT D403
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-1160
Practice Address - Country:US
Practice Address - Phone:623-466-2090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA086091790133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered