Provider Demographics
NPI:1700574621
Name:LONG, KATYA WOLF (RDN, LDN)
Entity type:Individual
Prefix:
First Name:KATYA
Middle Name:WOLF
Last Name:LONG
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:KATYA
Other - Middle Name:DORENE
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1114 FARRIS DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37912-5442
Mailing Address - Country:US
Mailing Address - Phone:484-716-0973
Mailing Address - Fax:
Practice Address - Street 1:1114 FARRIS DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37912-5442
Practice Address - Country:US
Practice Address - Phone:484-716-0973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000004185133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered