Provider Demographics
NPI:1841933025
Name:NICHOLSON, KATELYN ROSE (RDN)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 8TH AVE S
Mailing Address - Street 2:
Mailing Address - City:CLEAR LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50428-2610
Mailing Address - Country:US
Mailing Address - Phone:651-302-9433
Mailing Address - Fax:
Practice Address - Street 1:1302 8TH AVE S
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428-2610
Practice Address - Country:US
Practice Address - Phone:651-302-9433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-15
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079235133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic