Provider Demographics
NPI:1154659290
Name:WARREN, KELLI M (RD/LD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:WARREN
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 E KENOSHA ST # 265
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2007
Mailing Address - Country:US
Mailing Address - Phone:918-357-1501
Mailing Address - Fax:918-357-1501
Practice Address - Street 1:27761 E 61ST ST S
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-8515
Practice Address - Country:US
Practice Address - Phone:918-357-1501
Practice Address - Fax:918-357-1501
Is Sole Proprietor?:No
Enumeration Date:2009-12-01
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK539133V00000X
AR910133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered