Provider Demographics
NPI:1538779434
Name:WEDE, KAYLA LYNN (RD)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:LYNN
Last Name:WEDE
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 1:2026 PROMISE RD APT 4407
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-8974
Mailing Address - Country:US
Mailing Address - Phone:712-577-0749
Mailing Address - Fax:
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:605-385-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0730133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered