Provider Demographics
NPI:1386267631
Name:KONIARCZYK, CAITLIN JO (RDN)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:JO
Last Name:KONIARCZYK
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:JO
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-3861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-3861
Practice Address - Country:US
Practice Address - Phone:720-987-4627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT86070211133V00000X
RI86070211133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered