Provider Demographics
NPI:1902512379
Name:WOLFE, MARY KATELYN BRYANT (RDN)
Entity Type:Individual
Prefix:
First Name:MARY KATELYN
Middle Name:BRYANT
Last Name:WOLFE
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 1:108 LYDIA LN
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-5504
Mailing Address - Country:US
Mailing Address - Phone:731-695-5426
Mailing Address - Fax:
Practice Address - Street 1:108 LYDIA LN
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-5504
Practice Address - Country:US
Practice Address - Phone:731-695-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-27
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD-1851133V00000X, 133VN1201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered