Healthcare Provider Details

I. General information

NPI: 1396037818
Provider Name (Legal Business Name): KAITLYN BAILEY RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 05/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 US HIGHWAY 80 E NUTRITION DEPARTMENT
DEMOPOLIS AL
36732-3605
US

IV. Provider business mailing address

105 US HIGHWAY 80 E NUTRITION DEPARTMENT
DEMOPOLIS AL
36732-3605
US

V. Phone/Fax

Practice location:
  • Phone: 334-287-2560
  • Fax:
Mailing address:
  • Phone: 334-287-2560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2102T
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: