Provider Demographics
NPI:1366098600
Name:KIMBALL, KAYTLIN (RDN)
Entity type:Individual
Prefix:
First Name:KAYTLIN
Middle Name:
Last Name:KIMBALL
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 1:715 S 8TH AVE
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-6926
Mailing Address - Country:US
Mailing Address - Phone:971-404-4705
Mailing Address - Fax:
Practice Address - Street 1:715 S 8TH AVE
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-6926
Practice Address - Country:US
Practice Address - Phone:971-404-4705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10199329133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered