Provider Demographics
NPI:1306341813
Name:POWELL, CAITLIN ALEXANDREA (RD/LD)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:ALEXANDREA
Last Name:POWELL
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 1:2510 E INDEPENDENCE ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1839
Mailing Address - Country:US
Mailing Address - Phone:800-942-2904
Mailing Address - Fax:844-364-1309
Practice Address - Street 1:1002 S 4TH ST
Practice Address - Street 2:
Practice Address - City:KIOWA
Practice Address - State:KS
Practice Address - Zip Code:67070-1825
Practice Address - Country:US
Practice Address - Phone:620-825-4131
Practice Address - Fax:620-825-4667
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2258133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered