Provider Demographics
NPI:1699127464
Name:COSTELLO, KAITLIN MARIE (CNS, LDN)
Entity type:Individual
Prefix:MS
First Name:KAITLIN
Middle Name:MARIE
Last Name:COSTELLO
Suffix:
Gender:F
Credentials:CNS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 13TH ST SE
Mailing Address - Street 2:APT 2
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2224
Mailing Address - Country:US
Mailing Address - Phone:410-688-9009
Mailing Address - Fax:
Practice Address - Street 1:504 13TH ST SE
Practice Address - Street 2:APT 2
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-2224
Practice Address - Country:US
Practice Address - Phone:410-688-9009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX4032133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist