Provider Demographics
NPI:1356828651
Name:KING, KAYLEIGH (RD)
Entity type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 AUSTIN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-9740
Mailing Address - Country:US
Mailing Address - Phone:501-295-7105
Mailing Address - Fax:
Practice Address - Street 1:100 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023-8606
Practice Address - Country:US
Practice Address - Phone:501-295-7105
Practice Address - Fax:501-229-6070
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1621133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered