Provider Demographics
NPI:1891511994
Name:LEWIS, MCKYLIE RAELLEN (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:MCKYLIE
Middle Name:RAELLEN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:MCKYLIE
Other - Middle Name:RAELLEN
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4213 HATCH HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-1675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4213 HATCH HOLLOW LN
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-1675
Practice Address - Country:US
Practice Address - Phone:208-404-4873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-23
Last Update Date:2024-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1285133V00000X
TXDT91391133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered