Healthcare Provider Details

I. General information

NPI: 1841933025
Provider Name (Legal Business Name): KATELYN ROSE NICHOLSON RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1302 8TH AVE S
CLEAR LAKE IA
50428-2610
US

IV. Provider business mailing address

1302 8TH AVE S
CLEAR LAKE IA
50428-2610
US

V. Phone/Fax

Practice location:
  • Phone: 651-302-9433
  • Fax:
Mailing address:
  • Phone: 651-302-9433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number079235
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: