Healthcare Provider Details

I. General information

NPI: 1194647719
Provider Name (Legal Business Name): KT PERFORMANCE NUTRITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E BLACK ST
MARSHALL MO
65340-3332
US

IV. Provider business mailing address

214 E BLACK ST
MARSHALL MO
65340-3332
US

V. Phone/Fax

Practice location:
  • Phone: 515-460-1876
  • Fax:
Mailing address:
  • Phone: 515-460-1876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: KAITLIN N THIEL
Title or Position: REGISTERED DIETITIAN NUTRITIONIST
Credential: RDN, LD
Phone: 515-460-1876