Provider Demographics
NPI:1811455363
Name:MIKELAITES, KATHERINE ROUSE (RD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ROUSE
Last Name:MIKELAITES
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:301 E WENDOVER AVE STE 311
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1210
Mailing Address - Country:US
Mailing Address - Phone:336-272-6161
Mailing Address - Fax:336-230-2150
Practice Address - Street 1:301 E WENDOVER AVE STE 311
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1210
Practice Address - Country:US
Practice Address - Phone:336-272-6161
Practice Address - Fax:336-230-2150
Is Sole Proprietor?:No
Enumeration Date:2019-03-04
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered